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In order to provide you the best possible wellness care, please complete this form

Patient Data

How did you hear about Kirkland Whole Life Clinic?

Mailing Address

Current Complaints

Insurance Information

*If an auto accident, please provide:


I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Medical History

I give Kirkland Whole Life Clinic permission to contact my family doctor and other health providers for my medical history and treatment plan.

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Family History


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