New Patient Request Form

Please submit this completed form and you will be contacted to schedule your first appointment.

Phone Type *
If it’s a mobile number, would you like to receive text reminders for your appointments?
Is this your first time visiting our clinic? *

If it has been over 2 years since your last visit, continue with this form. If under 2 years, click here for the Patient Portal to make an appointment or update your information. Or call 360-823-0888.

Are you coming in for a motor collision or fertility? *
How do you plan to pay for services? *

We bill the following insurance companies: Aetna, Blue Cross Blue Shield / Regence / Anthem, First Choice, HMA, Humana Medicare Advantage, Kaiser / CHP, Lifewise, Moda, Multiplan, PacificSource, Premera, Providence, Triwest, United Healthcare / UMR. If you aren't sure if your plan is within one of these networks simply give us a call to ask at 360-823-0888.

Is your name the same on your insurance ID? *
Are you the primary subscriber on this plan? *
Do you have secondary insurance coverage? *

If you don’t have acupuncture benefits, but you have out-of-network benefits, we can charge you cash rates and provide you with a superbill so you can be reimbursed.