Trees

patient forms

Filed under: — Orna @ 12:00 am

Please download the following forms, fill them out and return them two days prior to your first appointment. You may fax them to 503.575.9229 or email them to celilo@celilohealth.com.


As part of our effort to reduce paper, most of these forms can be completed electronically. A small version of the adult intake form is also available for folks with slower internet connections or who plan to fill in the form by hand.


intake forms: choose one of these

• Adult intake form (smaller version)

• Adult intake form (large version, 1.8M) Works best using free Acrobat Reader.

• Pediatric intake form, for kids up to 5 years old

• Pediatric intake form, for kids 6 to 12 years old


other forms: please fill out all of these

• Informed Consent

• Your federally protected medical privacy rights

• Our agreement about your federally protected medical privacy rights

• Payment agreement

• Assignment of benefits (if we are billing your health insurance)


optional forms: for your convenience

• Release of records request to get records from other doctors sent here (optional).

• Insurance verification. Use this form to check your coverage for naturopathic care.




Need a copy of Acrobat Reader? Click here for the free download.

Address: 4921 NE 28th Ave. Portland, OR 97221 Phone: 503.335.9479 Taproot Hosting Site Design: Chipboard Creative | © Copyright 2014 Celilo Health