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!

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

Problem #1

Problem #2

Problem #3

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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