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
• Your federally protected medical privacy rights
• Our agreement about your federally protected medical privacy rights
• 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.
