New Patient Intake Documents (Webform)

Patient Information

(Mandatory fields marked with a "red-asterisk")

Patient Health History

Family Disease History:

Lifestyle / Diet (specify type, amount, frequency)

List foods you eat at:

Please indicate any CURRENT symptoms you are experiencing:

Office Policies & Fee Schedule

• Naturopathic treatments are individualized and often require modifications as treatment progresses. In between your office visits, I am happy to answer short questions to clarify your treatment plan instructions, via secure message on the Patient Fusion portal. However, email is not a substitute for an office visit. Your email questions should be no more than 3-5 lines long and pertain to your current treatment plan directly. If there is an acute or new concern, please schedule an appointment. If Dr.Seligman determines that your message is too complex, requires an in-depth explanation or professional advice, or will result in an alteration in your treatment plan, you will be advised to schedule an appointment so that the question(s) may be adequately and appropriately answered. Dr.Seligman is practicing by Telemedicine (video visit) exclusively. Some medical conditions may not be treated well by video call and you may be referred to an acute care clinic, Family practice setting or a specialist for further evaluation.
• Dr. Seligman is no longer contracted with any medical insurance companies and all services are provided on a fee for service basis. Fees vary depending on complexity and time of your visit. Typical new patient fee is $375 and typical return visit fee is $175.
• Email fees are not charged for clarifications to already provided service. Other emails that are unrelated to clarifications will incur a $50 fee or be asked to schedule an appointment.
• Fee for no show or late cancellation with less than 24 business hours notice for a new patient visit is $100 and return patient visit is $50.
• Dr.Seligman will strive to be conscientious of in-network coverage for lab and imaging referrals. It is your responsibility to check with your insurance company about coverage of any recommended diagnostic workup. Dr.Seligman cannot guarantee coverage of your labs, imaging or referrals through your insurance.
• Dr.Seligman can provide you with a bill for services that you can submit to your insurance plan as an "Out of Network provider".

By providing my credit card information below, I authorize Dr.Trina Seligman to keep my credit card information on file in a secure portal for payment of visit, cancellation, & email fees as well as any product purchases. If my credit card is declined I am responsible for immediate payment of the full balance by an updated credit/debit card. I understand that I can request an invoice from my visit or other billing.

Notice of Privacy Practices

Evergreen Integrative Medicine complies with the Health Insurance Portability & Accountability Act (HIPPA). We protect confidential health care information, known as “Protected Health Information” (PHI). Below is a summary of patient privacy rights under HIPPA and our clinic's legal duties and privacy practices regarding your PHI.

Uses & Disclosures of Your PHI

• We may use or disclose your PHI for payment of your services. For example, we may send a report of your progress to your insurance company.
• We may use or disclose your PHI for our normal healthcare operations. For example, one of our staff will enter your information into our computer.
• We may share your PHI with our business associates, such as billing service. We have a written contract with each business associate that requires them to protect your privacy.
• We may use your PHI to contact you. For example, we may send newsletters or other information.
• We may also want to call and remind you about your appointments. If you are not at home, we may leave this information on your answering machine or with the person who answers the telephone. In case of an emergency, we may disclose your PHI to a family member or another person responsible for your car.
• We may release some or all of your PHI when required by law.
• If this practice is sold, your PHI will become the property of the new owner. Except as described above, this practice will not use or disclose your PHI without your prior written authorization.

Patient Privacy Rights

• You may request in writing that we not use or disclose your PHI as described above. We will let you know if we can fulfill your request.
• You have the right to know of any uses or disclosures we make with your PHI beyond the above normal use.
• As we will need to contact you from time to time, we will use whatever address or telephone number you prefer.
• You have the right to transfer copies of your PHI to another practice. We will mail/fax your files for you.
• You have the right to see and receive a copy of your PHI, with a few exceptions. Give us a written request regarding the PHI you want to see. If you also want a copy of your records, we may charge you a reasonable fee for the copies.
• You have the right to request an amendment or change to your PHI. Provide us your request to make changes in writing. If you wish to include a statement in your file, please provide it to us in writing. We may or may not make the changes you request, but will include your statement in your file. If we agree to an amendment or change, we will not remove nor alter earlier documents but will add new information.
• You have the right to receive a copy of this notice.

If we change any of the details of this notice, we will notify you of the changes in writing. You may file a complaint with the Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, Washington, DC 20201. You will not be retaliated against for filing a complaint. However, before filing a complaint, or for more information or assistance regarding your health information privacy, please call our office at 425.999-4503. This notice goes into effect as of April 14th, 2003.

Federal law requires that we obtain your written acknowledgment of receipt of the Notice of Privacy Practices. The patient hereby acknowledges that Evergreen Integrative Medicine has provided a copy of its Notice of Privacy Practices that describes how protected health information may be used and disclosed, and how to access this information. I understand that if I have questions or complaints I may contact Evergreen Integrative Medicine. I also understand that I am entitled to receive updates upon request if Evergreen Integrative Medicine amends or changes its Notice of Privacy Practices in a material way.

Consent to Treatment

I hereby request and consent to the performance of naturopathic procedures (including examination, diagnostic testing, and the use of natural substances such as vitamins, minerals, botanical medicines, bioidentical hormones, and prescription drugs) on me (or on the patient named below, for whom I am legally responsible) by Dr. Seligman; a licensed Naturopath.

I understand and am informed that, as in the practice of medicine and naturopathic medicine, there are some risks to the exam and treatment including, but not limited to Naturopathic Medicine- drug side effects, nutrient-drug interaction, and herb-drug interactions. I understand and am informed that results from treatments may vary and are not guaranteed. In addition, I understand that my compliance with diet recommendations, supplements, prescribed medications, prescribed exercises, and lifestyle modification will increase the effectiveness of my care and enhance or maintain the results. I understand a referral to another physician or specialist may be necessary due to the nature of my condition and limitations in the scope of practice of Naturopathic Medicine.

I am aware that Naturopathic Physicians are considered primary care providers in the state of Washington. I acknowledge that the scope of practice of a Naturopathic physician has limitations including limited prescription privileges and lack of hospital privileges. Consequently, a referral to a specialist or emergency room may be deemed necessary under certain circumstances and in my best interest.

I do not expect the doctor to be able to anticipate and explain all the risks and complications, and I wish to rely on the doctor to be able to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts known.

I have read, or have had read to me the above consent. I have also had an opportunity to ask questions about its content, and by initialing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

Sign and Submit

Your agreement to all policies is required to complete this document and receive an appointment. If you have questions or concerns with any policy or part of this document please contact our office by email at staff@eimed.com.

My signature below is an indication that I have completed this document to the best of my abilities and have reviewed and agree with all policies presented.

Next Steps

• Please expect an email from staff@eimed.com within 48hrs containing instructions to select an appointment time.
• THIS EMAIL SOMETIMES ENDS UP IN JUNK MAIL. If you don't receive an email within 24hrs, please check your junk mail box and add "staff@eimed.com" TO YOUR SAFE SENDERS LIST
• If you do not find the email, please let us know by sending an email to staff@eimed.com.