Metabolic Masters Program

North Seattle Natural Medicine

617 5th Ave S. Edmonds, WA 98020

Phone: 206-629-5180
Fax: 206-629-5197

Basic Information

Patient's first name

Patient's last name

Age

Date of birth

Preferred gender pronoun(s)

Gender assigned at birth

Female

Male

Address 1

Address 2

City

State

Zipcode

Are you a returning/established Patient?

Yes

Name of Primary Care Provider

Contact Information for Primary Care Provider

If other than NSNM Provider

Medical History

List the prescription and non-prescription medications, vitamins, minerals, and herbs that you are currently taking, (include the dosage of each)

Please specify the patient's preferred pharmacy

Preferred pharmacy's phone number

Height

Weight

Acknowledgements

I acknowledge that individual results may vary and that no specific outcomes are guaranteed. I understand that treatment recommendations may change based on my clinical response, laboratory results, or other medical considerations. I further understand that I may choose to modify or discontinue treatment at any time, and that the provider may also recommend changes or discontinuation if medically indicated.

I acknowledge that my participation may contribute to a study or pilot program. I understand that any information shared for this purpose will be de-identified, labeled and reported only as aggregated statistics, and will not include information that directly identifies me. I acknowledge that de-identified results may be shared with a Harvard Medical School pilot program focused on improving nutrition education for medical students and continuing education for physicians.

I acknowledge that participation in this program requires recent laboratory results. I confirm that I either have current labs available for review, or I agree to obtain required laboratory testing within one (1) week of my program start date. I understand that failure to provide required labs may delay or prevent program participation.

Thank you for filling out our Metabolic Masters Program Form! Once you have submitted it you should expect to hear from us within 3 business days. If you have any questions feel free to give us a call. We'll talk to you soon!

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