New Patient Application

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Please tell us about yourself

MM slash DD slash YYYY
What are your preferred methods of communication? (Check all that apply)*

A little bit about insurance

Do you have active insurance coverage?*
Please confirm that you understand there is no guarantee with insurance coverage, you are still responsible for making sure that all required authorizations, pre-certifications and benefits are in order prior to & during treatment, and your insurance benefits are not a guarantee of payment, only a quote from your insurance company.*
Please confirm that you have reviewed our Rates, Insurance & Fees page.*
Were you in a Motor Vehicle Accident, AND have active Motor Vehicle insurance?*

How can we help?

Have you seen a Naturopathic Doctor before?*

What are your 3 main health goals?

Please confirm/acknowledge the recommendation for you to have established care or will establish care with a Primary Care Physician (PCP). We offer primary care services, but according to commercial insurance, we are not defined as a primary care physician (PCP): we are defined as specialists (naturopathic physicians).*

Can we stay in touch?

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