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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.

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 note if you have tried psychiatric medications in the past.
Please list any allergies (penicillin, trees, nuts, etc)
check all that apply
OK to select more than 1
OK to select more than 1

THANK YOU! Please click "Submit Form" to send to Village Family Clinic.

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