Click a link below to download and print a PDF form.
Please note: Our email is unencrypted. By choosing to email your forms to us, you understand and accept any risk associated with sending your information via email.
New Patient Forms
Please read over the New Patient packet for complete details and information regarding your New Patient appointment- including a list of medications to stop prior to your appointment. These forms may be printed, filled out and either brought in with you to your appointment, scanned and emailed to email@example.com* or faxed to 206.523.0724.
This updated form must be completed for appointments falling after 1.2.18 and updated annually. For families, you may list multiple children (and yourself) on this form. For patients over the age of 18, the form must be completed and signed by the patient. Please send completed and signed forms to firstname.lastname@example.org* or fax to 206.523.0724.
Consent to Discuss (for Adults, ages 18 and over)
This forms is used for Adults (ages 18 and over) only and must be completed and signed by the patient. Please send completed and signed forms to email@example.com* or fax to 206.523.0724.
- Consent to Discuss (Adults)
Consent to Treat a Minor
For minors (17 and under), you may complete the attached form, allowing someone other than parent/legal guardian to bring the patient in for established-care appointments or shots. You may list multiple children on the same form. *This section does not apply to the New Patient appointment. Parents/legal guardians MUST bring minor patient in to the New Patient appointment. Please send completed and signed forms to firstname.lastname@example.org* or fax to 206.523.0724.
- Consent to Treat (Minors)
Please complete the lower portion of the applicable form(s) and either email to email@example.com* or fax Att: Nurse Triage at the office where you see the doctor. Click here for a List of Locations with our fax numbers.
Note: We are happy to complete school forms on our patients who have seen a provider in last six months. If you would like your child’s school forms to be sent to your child’s school, please make sure you complete and sign the parent section prior to submission to us. Unsigned forms can only be returned to patients home address or picked up by parent/legal guardian.
If you are asking for the forms to sent to the school, please be sure to include the name of the school and fax# with your forms.
We are not able to email forms back to you unless you have a Portal Account.
If your child has not been seen in last six months we may not be able to complete forms without an appointment.
If you have checked with your insurance and have now decided to either start a Program of shots or want to request a renewal of your antigen, fill out this form and fax it to the Seattle office at: 206-523-0724 Att: Antigen Department, or email to firstname.lastname@example.org*.
Medical Record Form
Please complete and fax to the Seattle office at: 206-527-2514 Att: Medical Records Department, or email to email@example.com*.