Comprehensive Medical Center Kirkland | Health Care and Wellness Services

Patient's First Name

Patient's Last Name

Date of Birth

Gender:

Male

Female

Parent/Guardian If Applicable:

Phone Number:

Street Address:

City:

State:

Zip Code:

Country:

Email Address:

Chief Complaint/Reason For Seeking An Appointment

How did you hear about us?

Is there a specific provider at CMC you are interested in seeing?

Please comment on any illness marked above:

Include approximate dates and current status

If so, please describe:

Please comment on any illness marked above:

Please list your current prescription medications:

Please list your current supplements:

Do you have significant mobility issues? Difficulty walking upstairs? Wheelchair? Able to extend arms above head?

Anything else you think it's important we know (urgency, goals, expectations):

If required by your physician, are you willing to travel to Washington at least twice per year to be seen in person?

Note: “Thank you for you submission. We have received your application and you will receive a response within 5 business days to the email address on file. IF you do not hear back after 5 days, please feel free to contact the office.

The information submitted on this form is for screening purposes only and may not be kept on file. If our team decides we are not the best fit for your case and your application is denied, notification will be sent to the email address on this form.”

New Patient Intake Form

Do you have a history of any of the following:

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