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Patient Forms

 

Download Forms for Your Practitioner

Some Seattle Healing Arts practitioners offer patient forms that can be downloaded here. Forms are in PDF format (you will need Adobe® Reader to view them).

Click links below to download forms for your practitioner. Please print forms and fill them out. You can also save the forms to your computer and print them later.

Suite 200 - Practitioners

Patient Forms

Michael Byrne, ND

Dean R. Chier, MD

Christian Dodge, ND

Amy E. Hobson, ND

Eva Miller, ND

W. Bruce Milliman, ND

Fernando Vega, MD

Patient Registration form

Health History form

Patient Responsibilty Agreement

Privacy form

Privacy Practices notice

Notice for Well Exams

Authorization to Disclose Healthcare Info

Kevin Connor, ND, LAc

Patient Registration form

Health History form

Patient Responsibilty Agreement

Privacy form

Privacy Practices notice

Consent form

Authorization to Disclose Healthcare Info

Notice for Well Exams

 

Trina Doerfler, DC, ND

 

Patient Registration form

Health History form

Health Concerns Checklist

Consent form

Patient Responsibilty Agreement

Privacy form

Privacy Practices notice

Authorization to Disclose Healthcare Info

Notice for Well Exams

About Quantum Health/Quantum Neurocare

 

Takla E. Gardey, MD

Angela Heithaus, MD, PS

Martina Koller, MD

Patient Registration form

Adult Health History form

Child Health History form

Patient Responsibilty Agreement

Privacy form

Privacy Practices notice

Authorization to Disclose Healthcare Info

Notice for Well Exams

 

Jane Pemberton, MD

Patient Registration form

Health History form

Child Health History form

Patient Responsibilty Agreement

Privacy form

Privacy Practices notice

Authorization to Disclose Healthcare Info

Notice for Well Exams

 

Zhi-Ping C. Kolouch, LAc, PhD

Patient Registration form

Medical History form

Patient Responsibilty Agreement

Privacy form

Authorization to Disclose Healthcare Info

 

Karim Abdullah, ND, LAc

Patient Registration form

Health History form

Patient Responsibilty Agreement

Cancellation policy

Privacy form

Privacy Practices notice

Authorization to Disclose Healthcare Info

Notice for Well Exams

 

3rd Floor Practitioners

Patient Forms

 

Christiane Elsbree, MSW, LICSW

 

Disclosure & Client Agreement

Patient Intake Form

Insurance Form

Parent Handout

 

 

 
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