NSNM New Patient Prescreening Form

Please correct the errors described below.

North Seattle Natural Medicine

617 5th Ave S. Edmonds, WA 98020

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

First Name

Last Name

Date of Birth

Sex at Birth

Male Female Unknown

Please briefly describe the reason for your visit. What are you hoping to address, achieve or learn from this appointment? Feel free to share any specific concerns, symptoms or health goals you'd like to focus on.

Contact Details

Primary Phone

Email Address

Address Line 1

Address Line 2

City

Zip Code

Are you a returning/established patient?

No Yes

Insurance Details

Do you plan to use your insurance?

Yes No

Insurance Company or Plan Name

Insurance ID #

Have you verified your preferred NSNM Provider is in network with your Plan?

Yes No

I acknowledge that it is my responsibility to confirm that my preferred doctor is in network with my specific insurance plan and if my plan will cover visits with said doctor before my first appointment/upon renewing my insurance.

Chief Complaints

List your current health concerns that you would like to address at your intake visit (prioritize order of importance)

Chief Complaint #1

Date of Onset

Describe

Chief Complaint #2

Date of Onset

Describe

Would you like to establish primary care with your NSNM provider?

Yes No Unsure

Preferred Provider (If Available)

If your preferred Provider is not available, which Doctor would be your secondary choice?

Different form your first choice please.

How did you hear about us?

Sign Name

Date

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North Seattle Natural Medicine

617 5th Ave S. Edmonds, WA 98020

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

North Seattle Natural Medicine

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