A confidential, encrypted intake form that prepares your full medical record, consent forms, and pre-procedure checklist — all signed digitally and saved as a PDF for your file.
A complete pre-visit package, organised the way Dr. Powell-Jackson's team works.
Full personal details, emergency contact, photo, and insurance — captured once, saved to your patient file.
Medications, allergies, surgical history, and current concerns — reviewed by your physician before you arrive.
Procedure-specific consent forms signed with your finger or mouse. A PDF copy is generated automatically.
Take your time — your progress is preserved between sections.
Choose what you're scheduled for — the form adapts to show only what's relevant.
Personal info, health history, and procedure-specific questions in clear sections.
Draw your signature on the consent pads using your finger, stylus, or mouse.
Your form is saved to our database and a signed PDF copy is generated for your records.
A few things to have nearby will make this faster.
Photo ID
Passport, driver's licence, or national ID — image only, no data extracted automatically.
Insurance Information
Provider name and policy number — primary and secondary if applicable.
List of Medications
Current prescriptions and supplements including dosage if known.
Emergency Contact
Name, relationship, and phone number of someone we can reach.
Yes. Your data is transmitted over an encrypted HTTPS connection and stored in Google's HIPAA-eligible Firestore database. Only authorised SNJ Concierge staff have access. We never share data with third parties.
Your form is saved instantly to our patient records database and a PDF copy — including your digital signature — is generated for download and printing. Our staff will review it before your appointment.
Absolutely. After you submit, you'll be given options to download a signed PDF and to print the form using your browser. We recommend keeping a copy for your records.
Please call our office and we'll update your record directly. Submitted forms are not editable from this portal to maintain a clean audit trail.
It's best to complete it in one session as data is not auto-saved between visits. The form takes most patients about 10 minutes.
Reach our office at the number on your appointment letter, or speak to the front desk staff when you arrive. They're happy to help complete the form with you in-clinic if needed.
Your visit begins with this form. Take your time — we'll see you soon.
Begin Patient Intake