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 July 1st, 2024, Dr. Jennifer Lush and Dr. Robin Sinclair will transition to a combined membership/concierge model, providing enhanced and personalized healthcare services to their patients. This transition reflects our commitment to offering flexible and comprehensive healthcare options tailored to the diverse needs of our patients. For more information on the plans that Dr. Lush and Dr. Sinclair are offering please see our website page https://www.northseattlenaturalmedicine.com/about-3-1

Dr. Tausend will continue under the Elemental/Deluxe plans for the remainder of the year, and will transition to the concierge model January 1, 2025. For more information on the plans that Dr. Tausend is providing care under, please see our website https://www.northseattlenaturalmedicine.com/about-3

Rest assured, if you elect to transfer to one of our other providers, Doctors Lush, Sinclair and Tausend will be available to your new provider for consultation and case management. Please choose a plan below.

* Does not apply to patients covered by Medicare, Medicaid, or any other government payor, as well to those patients who are paying out of pocket due to insurance coverage.

List your current health concerns that you would like to address at your intake visit (prioritize in order of importance). Please specify "annual exam" if you want this appointment to be your routine annual physical. Please note, additional concerns may require additional appointments to address.

Problem #1

Problem #2

General Information

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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