11522 NE 20th Street, Bellevue, WA 98004
Tel: 425.462.2531 Fax: 425.454.6176


Filling out forms take time, but…

It’s important that we really get to know you. These forms help us deliver individualized medical care. To help expedite your first visit, we request that you complete the health assessment questionnaire, authorization to release medical records, insurance information, medical history and review of systems forms, as well as the office policy agreement. Please fill them out as completely as possible and bring them with you when you come in.  PLEASE ONLY USE A BLACK INK PEN WHEN FILLING OUT THESE FORMS!  Thank you.


Downloadable Forms 

Insurance Information Form

Medical History Form

Review of Systems Form

Medical Records Form

Health Assessment Questionnaire Form (HAQ)

Office Policy Agreement


If you would like us to release and/or receive your medical information, please fill out the corresponding form(s) below.                                                                                                                                                    

Release "To"

Release "From"