New Patient Adult Intake Form (Ages 13+)

Please correct the errors described below.

Basic Information

We do not have a system that can verify whether or not your insurance is covered for your preferred Provider. Is it your responsibility to verify that your doctor is in network.

**Also, Please contact your Insurance to see if you are covered and if a Prior Authorization for Acupuncture is needed**

Please note, due to the differences in each patient's insurance plan we rely on you to know your coverage. You can visit our website at https://www.northseattlenaturalmedicine.com/insurance to verify your insurance!

Starting January 1st, 2023, for patients who want to see Dr. Lush or Dr. Sinclair we are moving to a combined membership / insurance billing model that will allow for continued quality of care while delivering added patient benefits. Several membership tiers will be offered, intended to fit most patients’ needs and budgets. For those patients who still want to see either Dr. Lush or Dr. Sinclair, but who don't want to subscribe to a membership plan, there will be a pay per visit option (Elemental). For those who elect not to participate in a membership plan or pay additional fees, your care will be transferred to one of our other providers, of your choice, who will be ready to help you continue your health journey. Rest assured, if you elect to transfer to one of our other providers, doctors Lush and Sinclair will be available to your new provider for consultation and case management.

***Please note that you do not need to start paying until January 2023. ***

List your current health concerns (prioritize in order of importance)

Problem #1

Problem #2

Problem #3

General Information

Even if you put "YES", please write in that you did, so it can be submitted

Medical History

Review of Systems

Family Medical History

Over the last two weeks how often have you experienced any of the following problems?

Thank you for filling out our New Patient Intake Form! Once you have submitted it you should expect to hear from us within 5 business days. If you have any questions feel free to give us a call. We'll talk to you soon!

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