Forms

NEW PATIENTS
1. New Patient Registration
2. Supplemental Contribution Form
​3. Patient Health History
4. Notice of Wellness Exams
5. Patient Responsibility Agreement
6. Privacy Practices Notice
​7. Medicare Opt Out (only if self-pay Medicare patient)
​8. Telemedicine Informed Consent 
​9. Release of Medical Information

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ESTABLISHED PATIENTS
Change of Address or Insurance Form

​FORM DELIVERY
You can download these forms to print and fill out, or you can fill them out electronically. Please deliver your completed forms at least two days prior to your first appointment​ by FAX, email or mail. We will have you sign the forms when you get here. 
Email: info@deanchiermd.com
FAX: 206-906-9246
Mail: Dean Chier MD, 2611 NE 125th St. Suite 90, Seattle, WA  98125