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Jacksonville Health & Wellness Center offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our office.


1ST VISIT OFFICE FORMS (PAPER)  

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us your printed and completed form(s) or bring it with you to your appointment.
  • NOTE: For ALL our functional medicine appointments, please call our office to gain access to our on-line portal where you will be directed and given instructions on how to complete our in-depth medical history review. This must be completed BEFORE your upcoming visit with the Doctor. The analysis will help to create a 30-page custom report for your upcoming visit -- see below "Functional Medicine (On-Line Portal). Please Note: If you complete the on-line portal history, you DO NOT have to fill out the "Functional Medicine (Paper Forms) as this option is only for patients that do not have access to a computer.

Chiropractic, Massage and/or Physical Therapy
Functional Medicine (Paper Forms). Please Note: This Option is NOT PREFERRED
Mental Health Counseling

Functional Medicine (On-Line Portal)

MISCELLANEOUS FORMS

Child Neurotransmitter and Nutrition Questionnaire
Child Toxin Exposure Questionnaire
Metabolic Assessment Questionnaire
Depression Anxiety and Stress Questionnaire
Adult Neurotransmitter Questionnaire
Adult Toxin Exposure Questionnaire
Adult Medical Questionnaire I
Adult Medical Questionnaire II



Download the Free AdobeReader®

WANT TO UNLOCK YOUR HIGHEST POTENTIAL?

WANT TO UNLOCK YOUR HIGHEST POTENTIAL?

Are you sick and tired of being SICK AND TIRED?

Are you disillusioned with conventional treatments that lack focus on CAUSE, PREVENTION, DIET AND LIFESTYLE?

Sign up below to start your journey! We will assess your goals and guide you on your very first steps to reclaiming what is rightfully yours -- your HEALTH! We work with individuals in both the local Jacksonville area as well as those who are out-of-state.

Confused where to start? Click below to learn more about our seminars, one-on-one coaching, and on-line programs.

To begin, we will provide you with our FREE E-books, FREE 21-Day Jump Start Wellness Program and Newsletter to get you ready for your upcoming journey.

THIS ---->https://drrepolecom.chiromatrixbase.com/online-forms.html

Office Hours

DayOpenClosed
Monday9am6pm
Tuesday9am6pm
Wednesday9am6pm
Thursday9am6pm
Friday9am6pm
SaturdayClosedClosed
SundayClosedClosed
Day Open Closed
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9am 9am 9am 9am 9am Closed Closed
6pm 6pm 6pm 6pm 6pm Closed Closed

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