Fit Wellness Centers
5401 Leary Ave NW
Seattle, WA 98107

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information

Personal Information
Contact Information
Feet Inches

(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)


Draw Your Symptoms

Click on a crayon and draw on the body above to indicate your symptoms
Ache / Dull Sharp / Stabbing Numb / Tingling Pins & Needles Burning Throbbing Cramping Radiating Other Pains eraser eraser clear

Employment Information

Current Symptoms

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If Yes, Where?

Insurance & Payment for Care

Primary Insurance
Secondary Insurance

If an auto accident, please provide:

Personal Health History

Family/Primary Physician

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Family Health History

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(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)

Social History & Life Choices:


Reason for this Visit

If you're only here for chiropractic wellness services please skip this section.

Does this concern interfere with:


For Women Only


Goals for Your Care

People see a chiropractor for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible.

Health Problems & Concerns:

Please select all that you have had or currently have.


Thank you for choosing Fit Wellness Centers and its providers for your medical treatment and care. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we developed this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request. 1. Insurance. We participate in most insurance plans, If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, but don’t have an up-to- date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. Some insurance companies may require pre-authorization before receiving certain procedures, if you know this is the case, please let us know, so we can help facilitate any processing of forms to ensure timely care is achieved. 2. Co-payments, Co-insurance and deductibles. All co-payments, co-insurance and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit. 3. Non-covered services. Please be aware that some and perhaps all of the services you receive may be non-covered or not considered reasonable or necessary by insurers. You are responsible to pay for these services. We typically bill for office visits, procedure codes specific to Acupuncture or Naturopathic services and some codes that may also be used for modalities such as physical therapy. 4. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We will make a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. 5. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract. 6. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you. 7. Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. 8. Missed appointments. It is the policy of Fit Wellness Centers to allow customers to cancel appointments without charge until the end of the business day prior to the day of the appointment. For appointments cancelled on the same day as the appointment, Fit Wellness Centers will use best efforts to rebook the appointment. If unsuccessful, clients will be charged 50% of the appointment cost unless the cancellation was within 1 hr of the appointment or the customer was "no show, no call" for which the customer will be charged the full price of the appointment. For "same day" booked appointments, customers are allowed a one-hour grace period from time of booking to cancel their appointments without charge. Thereafter, same day cancellation policy rules apply. I authorize Fit Wellness Centers to use the card on file to pay for any outstanding balances, including copays, coinsurance, and all other account charges under patient liability. 9. Typical Billing Codes: Acupuncture/Naturopathic Visits Office visits --99201-99398 We provide and bill for office visits on most visits. Office visit services include provider consultation time spent with you discussing your particular medical issue(s), treatment plan, etc. These charges are easily recognizable on your explanation of benefits as they start with numbers 99. Occasionally, charges for office visits may change your deductible, copay or coinsurance for that particular visit. You may wish to consult your insurance company regarding any changes to your coverage based on a "specialist" office visit. Acupuncture Codes -97810,97811,97813,97814. Our Acupuncturists typically provide services requiring 2 of the acupuncture codes be billed. Almost all insurances will cover these codes if you have acupuncture coverage on your policy. It is unusual, but not unheard of, for an insurance company to deny a second acupuncture code. Manual Therapy Codes-97140. Tua Na is a traditional Chinese Medicine discipline used on all our Acupuncture visits. It is billed under the 97140 code. We feel Tua Na is a necessary part of your treatment and we bill this code on every visit. Our Naturopathic Physicans also use the manual traction code 97140 for bill for muscular manipulation work they do. This particular code can also be used by Physical Therapists, Chiropractors and possibly other healthcare professionals. You may wish to check with other providers to see if they are billing this code for your visits. Naturopathic Physical Medicine Codes-(98925-98929);97012;97140,97110. Naturopathic Physicians provide spinal manipulation services(Codes 98925- 98929),mechanical traction (97012),manual therapy (97140) and have patients perform specific therapeutic exercises (97110). If you are seeing a physical therapist, chiropractor or other physical medicine provider we recommend having them call us to coordinate care and benefits. Other Codes. Our Naturopathic Physicians also provider ultrasound (97035),Electrical Stimulation(97032);Injection therapy (96732,J3420,J3415,J3411) Biofeedback – (90901) Biofeedback refers to the use of biofeedback equipment to understand physiologic response to treatment. I certify that I'm the patient or legal guardian listed below. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to Fit Wellness Center’s and it’s practitioners. I authorize this office and its staff to examine and treat my condition as the practitioners see fit. I hereby authorize the practitioners to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. You will be asked to fill out a consent form in office for various treatments provided in office. Additionally a non-covered service form may be required in office if a service is not covered by your insurance. I have read and understand the payment policy and agree to abide by its guidelines:

Name of the Insured:
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Patient's/Guardian's signature:


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