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

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.

No Comments

Sorry, the comment form is closed at this time.

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