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Available Forms

#3 NEW PATIENT Health History form

Insurance information

We accept Regence, Premera, and most BCBS plans. We offer a time-of-service discount for patients with out-of-network insurance plans - please contact us for more information.

Health History

This health history form is for new patients for their initial visit. This information is securely imported into your chart.

MM/DD/YYYY
 
 
 
 
check all that apply
 
(Please include any illnesses that were not include in list above)
 
please type none if applicable
 
please describe any serious injuries
 
Please list any medications or supplements you are taking with dose and frequency.
 
Please specify dates you took the medication and the dosage
 
Please list any allergies (penicillin, trees, nuts, etc)
 
 
 
 
 
 
 
 
 
 
 
 
check all that apply
 
 
OK to select more than 1
 
OK to select more than 1
 
 
 
 
 
 
 
 

IMPORTANT INSURANCE INFORMATION BELOW

COVID screening

If you have answered 'yes' to any of these questions, please contact us to reschedule your visit. Thank you for understanding.

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