Download the online version of our form. You fill it out and print from your computer, or just print and fill it out by hand. Send it with the patient or fax to us at 425-320-4285.
IMPORTANT: The form can be filled out on your computer, but you must print it before closing the file. The information cannot be saved in the form.
You need Adobe Acrobat Reader to view our form. Please download the free Acrobat Reader from Adobe's web site if it is not already installed on your system.