Patient Full Name
*
Patient Date of Birth
*
Email Address
*
Mailing List
Add me to your Mailing List to receive communications about what's going on in the practice.
Phone Number
*
Mailing Address
*
Preferred Payment Plan
Annual Fee Program: We bill your insurance. A non-covered benefits fee of $20/mo for individuals, or $40/mo for families applies because of additional services we offer (full listing available under "Payment Options" tab of our website).
Cash Pay Program: Cash pay at time of service
Insurance Carrier
Lifewise
Regence (not Selections)
Premera
Blue Cross / Blue Shield
First Choice (not KPS or Providence)
Cigna
I don't have insurance (I will be using the Cash Pay option)
Pacific Source
Adventist
United Healthcare
Other:
New Patient Notes If you have anything else about you you'd like us to know, please share that information here. Please do not use this space for private patient-practitioner information.
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