New Patient Health History Form
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In order to provide you the best possible wellness care, please complete this form
How did you hear about Kirkland Whole Life Clinic?
*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.
I give Kirkland Whole Life Clinic permission to contact my family doctor and other health providers for my medical history and treatment plan.
Sign-up using the form or call us at 425-285-9020 to take advantage of this exclusive offer.
Please call to make an appointment
outside of regular hours.
* We are closed on New Year's Day, Independence
Day, Thanksgiving and Christmas.