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Naturopathic primary care form

Personal Information

 Feet    Inches

Contact Information

( We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice. )

Employment information

Insurance & Payment for Care


Primary Insurance



Personal Health History

Family/Primary Physician

Health Problems & Concerns:

Medication information

Separate the list Medicine Name/Frequency/Dosage with ",".

Family Health History

Separate details with "," comma as shown above.

Social History & Life Choices:

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Reason for your visit









 

 





For Women only

COMPLETE THIS SECTION ONLY IF YOU ARE (OR THE PATIENT IS) A WOMAN OVER 16 YEARS OF AGE.




Goals for Your Care

People seek holistic Naturopathic care for a variety of reasons. Some come to our clinic for relief of pain or help with emotional issues, some for resolving acute or long term imbalances in their body systems, and others for preventative health maintenance. The practitioners at Greenleaf Healthcare will work with you to implement a sustainable health plan that optimizes your well-being.

Please check the type of care desired so that we may be guided by your wishes whenever possible.

  •   Symptomatic relief of pain or discomfort for acute episodes
  •   Going deeper to address and heal the underlying cause of the presenting symptoms
  •   Using Naturopathic care to bring the body and mind into its highest state of health

Authorization

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the use of the above information for my treatments at Greenleaf Healthcare.. I authorize this office and its staff to examine and treat my condition with my active involvement. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon my care or treatment.
Our policy for missed appointments: A charge of 50% of the visit cost, for a No-show or Non-cancellation less than 12 hours before the appointment time.
I authorize Greenleaf Healthcare to use the card on file to pay for any outstanding balances, including copays, coinsurance, and all other account charges under patient liability.

Finalizing Form

  1. Print Form (optional)
  2. Submit Form!

  • 5227 Ballard Avenue Suite 5 Seattle, WA 98107
  • Phone: (206) 359-0094
  • Fax: (866) 730-7050
  • support@greenleafhealthcare.org

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