Intake

Five questions. Fifteen minutes.

A short intake helps your nurse prepare for a focused, free 15-minute consultation. You can also request an appointment and choose a membership below — all optional.

About you

Basic contact so a nurse can reach you.

Full name *Email *PhoneBest way to reach you

5-question core intake

These help your nurse understand the most common core measures and priorities.

1. Who is this care for? *2. What best describes your current health situation? *3. Core health measures you'd like a nurse to reviewSelect any that apply.4. What type of assistance are you requesting? *5. What outcome would make this feel like a win? *

Appointment request

Tell us when a 15-minute consultation would work best.

Preferred dayPreferred time windowTime zoneUrgency

Membership (optional)

Interested in ongoing support? Choose a plan and we'll confirm on your consultation.

None right now — just the consultationEssential$99/moPremium$249/moVIP$599/mo

HIPAA notice & patient consent

Please read carefully. Your signature below is required for legal and privacy compliance.

Patient-focused disclaimer

Proxymal Care is a registered-nurse–led patient education, navigation, and advocacy service. Proxymal Care does not diagnose medical conditions and does not prescribe medications, treatments, or therapies. Any care plan, education, or coaching provided by Proxymal Care is discussed only after a plan of care has been initiated by your current physician or licensed provider, and is delivered in support of — never in place of — that provider's clinical judgment.

Your protected health information (PHI) is handled in accordance with the Health Insurance Portability and Accountability Act (HIPAA). Information you share is used solely to coordinate your education and advocacy support, is stored securely, and is never sold or shared with third parties without your written authorization, except as required by law.

I acknowledge that Proxymal Care does not diagnose or prescribe, and that all education and care-plan discussions occur only after my current physician or licensed provider has initiated a plan of care.I give my informed consent for Proxymal Care nurses to discuss my medical conditions, medications, labs, and related health information with me (and, where I designate, my caregiver) for the purpose of education, navigation, and advocacy.I have read and understand the HIPAA privacy notice above and consent to Proxymal Care's collection, secure storage, and use of my protected health information (PHI) as described.

Nurse-driven, physician-partnered. Proxymal Care is a registered-nurse–led education and advocacy service. We do not diagnose, prescribe, or replace your physician or care team. All education supports health literacy, informed advocacy, and works in conjunction with your providers toward your optimal health.