New Patient Appointment Request

Our Clinical Focus

We provide specialized physiatric care and electrodiagnostic testing, with particular expertise in:
- Electrodiagnostic testing (EMG/NCS) for nerve and muscle disorders
- Motor vehicle accident injuries and whiplash
- Work-related injuries (L&I claims)

Insurance Accepted:

AUTO INJURY INSURANCE
✓ PIP (Personal Injury Protection)
✓ Third-Party Claims (through attorney representation)

WORKERS' COMPENSATION
✓ Washington State Labor & Industries (L&I)

PRIVATE INSURANCE
✓ First Choice Health Network*
✓ Kaiser Permante, PPO*
✓ Regence*

SELF-PAY
✓ Available with same-day payment discount

*Accepted plans vary—we verify coverage during scheduling

Questions about coverage? Call (425) 678-2044 before scheduling.
Who is filling out this form?*

MyselfSomeone ElseReferring OfficeAttorney
Relationship to Patient
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Gender:
Cell Phone:*
Please enter a valid phone number.
Is an Interpreter Needed?*

YesNoUnknown
Which Language Interpreter is Needed? please specify*
E-mail Address:*
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance Information:
Which Insurance are you Using?*
We do not accept: Medicare, United Healthcare, Community Health Plans, Molina/DSHS/Medicaid, Apple Health, Cigna, Premera and Aetna. We do not accept: Self-insured worker's compensation claims [City of Seattle, CorVel, Eberle Vivian, Gallagher Bassett, Penser, Sedgwick, Etc.]
Date of Injury:*

MonthDayYear
Date
Did your accident occur in WA state?*

YesNo
Motor Vehicle Insurance Name (Your Insurance):*
Please provide your motor vehicle insurance name for selected insurance. PLEASE NOTE: This is not for the other party's insurance.
MVA Claim Number:*
Please provide your claim number for your motor vehicle accident.
Claim Adjuster's Name:*
If you know the name of the claim adjuster assigned to your MVA claim please list it here. If you do not know write N/A. PLEASE NOTE: All Geico claims must provide claim adjuster's information.
Claim Adjuster's Phone Number:
Please include your claim adjuster's phone number, we might be unable to verify PIP coverage if this is not provided.
Attorney's Office Phone Number:*
Paralegal Name:
Paralegal E-mail:
example@example.com
Has a referral been faxed to our of office?

YesNoI don't know.
L&I Claim Number:*
Claims Manager's Name:
Claims Manager Phone Number:
Please enter a valid phone number.
Member ID Number:*
Please provide member ID number, prefix included. Specific plan network will be verified with patient during the time of scheduling.
Group Number:*
Self-Pay Consultation Fees
- Initial Evaluation: $350-$600
  Fee depends on complexity and time required. Most standard evaluations are $350-$400. Complex cases (multiple injury sites, detailed EMG review, MVA/legal claims) may be $450-$600.
- Follow-Up Visits: $200-$400
- EMGs and Procedures (injections, etc.): These add additional cost, discussed before treatment. You can get an estimate when you call.
- 20% Discount Available: Pay at time of service
Questions about expected costs for your specific case? Call (425) 678-2044 - we can provide an estimate before your appointment.

Referring Information:
Referring Care Provider/ Self-Referred:
If referred by a provider please include their credentials. IE: DC, DPT, ARNP, PA-C, MD, DO, PA-C, Etc.
To provide you with the best care, I need to understand what's most affecting your daily life right now. Please list your main concern first, followed by any other symptoms (secondary concerns) or issues you'd like addressed. This helps me prioritize our evaluation and treatment plan.
Primary Concern:*
What's most affecting you right now?
Secondary Concerns?
Please list any other symptoms or areas of concern. I'll assess what we can reasonably address during this appointment. Some issues may benefit from a dedicated follow-up visit where we can give them proper attention.
Recent Imaging or Testing:Have you had X-rays, MRI, CT scan, EMG, or other testing for this condition?

YesNo
Please tell us what imaging or testing you have had done:
Please include where and when you have received your imaging/testing if known.
OPTIONAL: Please upload any relevant documentation here:

Cancelof

Thank you! Your initial intake form is now complete. Be sure to click Submit above.
- We'll contact you within 3-5 business days to schedule your appointment.
  Typical availability: 2-4 weeks. EMG's can usually be scheduled even sooner.
- Note: This is a specialty physiatry clinic, not an urgent care or walk-in facility. If you need immediate care, please visit urgent care or your primary care physician.
Questions? care@soundinjury.com | (425) 678-2044
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