Forms

New Patient Forms:

Please print and complete the following forms to bring with you to your New Patient appointment. If you are unable to complete and fill these forms, please arrive 30 minutes prior to your scheduled appointment time to complete these at our office. 

• Adult Patient Information Form
• Child Patient Information Form
• Family Health Questionnaire
• Financial Policy updated 9-19-2022 updated
• Patient agreement insurance coverage 9.14.22
• Patient Portal Sign up
• Medical Records: Release of Information – Please ensure to fill out this form entirely to ensure their are no delays in obtaining your previous records. 

–

Financial Assistance:

We’re excited to offer financial assistance opportunities in partnership with MultiCare. Please download and submit the completed forms below and submit as directed on the application. 

• MultiCare Financial Assistance Application 

–

Child Wellness Visit Questionnaires:

Please print and complete the appropriate forms to bring with you to your your child’s wellness appointment. If you are unable to complete and fill these forms, please arrive 30 minutes prior to your scheduled appointment time to complete these at our office. 

• ASQ 9 Month Questionnaire
• ASQ 18 month Questionnaire
• MCHAT-R (18 Months)
• ASQ 24 Month Questionnaire

– 

Medical Records:

**Please ensure to fill out this form entirely to ensure their are no delays in obtaining your records. **

• Medical Records: Release of Information

– 

Other Forms:

• Medicare Wellness Questionnaire
• Change of Information Form
• Notice of Privacy Practices
• Auth for Evaluation and/or Treatment of a Minor Child w/o Parent or Guardian