Forms

Prior to your visit, you will need to call the clinic at 971-319-0045 so we can register you and send you the intake forms.

Once you schedule, please call the clinic so we can collect some information from you in order to sign you up for the patient portal. We will also email you the intake form, consents and the insurance verification form to complete prior to your appointment.

For your convenience, you can also download the forms in the following sections:

Patient Intake Form

The patient intake form helps you to provide us with contact information as well as your current and historical general health and wellness. It gives us a broad overview and a starting point for getting to know you and your health care needs.

Here are a few specialized intake forms that you can fill out if they apply to your specific needs.

Insurance Verification Form

The insurance verification form is the form you will you use to make sure you obtain needed information when you call your provider to verify your insurance coverage (e.g. providers and services that are covered in and out of network, deductibles, number of visit limitations, etc.).

Release of Records Form

If you have any lab or imaging records from the previous year from another provider, please fill out the Release of Record Form. You can either submit to the outside provider yourself or email the completed form to us and we will coordinate for you.

Consent Forms

The Consent form below is for existing patients needing to update their information with us such as address, insurance and contact information. This will also need to be signed annually in agreement with HIPAA policies.

Consent and Polices Signature Form

Policies

The HIPAA Privacy Practices is a more detailed explanation of our policies for your reference.

Clinic Policies and HIPAA Privacy Practices

The Good Faith estimate and Fee schedule reviews the codes we commonly bill with both insurance pricing and self-pay pricing for those not using insurance.

Good Faith Estimate and Fee Schedule

Treatment Forms

The following forms are pre and post procedure information for patients having the Mona Lisa Touch procedure.

The form below is information for pre and post procedure care for patients having the Thermiva procedure.

Thermiva Pre and Post Procedure Form

Patients coming in for IV Therapy need to complete the IV Therapy Intake prior to your first IV visit and we will have you sign an IV Consent Form upon arrival.

Please complete these questionnaires for your doctor to have a baseline for your anxiety and depression. We may have you complete these at subsequent visits as well.