EASTSIDE REGENERATIVE MEDICAL| For Our New Patients | (425) 899-2525   

Patient Forms

For your convenience, please download, complete, and sign the following Health Center forms prior to your first appointment.  The forms use Adobe Acrobat Reader. If you don't have a copy of Acrobat Reader, you can click the icon below and download it for FREE.

We have compiled a complete, NEW PATIENT PACKET for you to download and complete prior to your first visit. This will save you some time at your initial visit with us. Simply download the packet, print it, fill it out and bring it with you to your first visit.
What's included in the packet:
  • Confidential New Patient Information
    Your personal information remains private and confidential at our offices.
  • Clinic-Patient Agreement
    This form explains the guidelines and policies that we use to provide you with the highest quality of medical care. 
  • Financial Policy
    This form explains our policies for payments and deductibles. 
  • Privacy Practices Acknowledgement (HIPPA)
    This form explains how we comply with the Health Insurance Portability and Accountability Act (HIPPA) to protect your personal information. 
  • Authorization for Release of Health Care Information and Records 
    This form allows us to view and use your medical records and to provide these records and information to our medical partners. This allows us to more efficiently and effectively care for your medical needs. 
  • Patient Information Sheet
    This form contains general information about you that our doctors and staff use to expedite your health care. 
  • Medical History
    This form contains information on your current and past medical history. 
  • How this injury has affected me (Impairment Ratings Only)
    If you are coming in for an impairment rating, use this form to record how the injuring has affected your ability to perform tasks and activities. 
  • Cancellation/No Show Policy
    Complete details of our Cancellation/No Show Policies.

Guidelines and Policies

At Eastside Regenerative Medical, it is our commitment to provide you with the highest quality of medical care, and we’d like to work with you to accomplish this goal.  To make this process simple and straightforward, we’ve outlined a few clinic guidelines and policies.

Prescription Refills

For our patients who need refills on their medication(s), please contact your pharmacy directly to request a refill.  Since it usually takes 4~5 business days to get a refill, please contact your pharmacy 4~5 days before you are completely out of the medication(s). The following medications require an office visit for refills: Pain Medications, Anti-Depressants, and Sleep medications.

Please note: We will not replace lost or stolen prescriptions of narcotics or controlled substances.

Diagnostic Tests & Laboratory Results

We use Medical Diagnostic Laboratories / Skagit Valley Pathology for most of our laboratory services. Please allow 5~7 business days for the results of Diagnostic Tests such as MRIs, CT Scans, X-rays, & Ultrasounds, and Lab results such as Surgical Pathology reports, Blood tests, etc.  The results are typically discussed with your provider only at an office visit.


Some insurance plans (HMO, EPO, etc.) require referrals from their Primary Care Physician (PCP) before a patient is allowed to see a specialist, massage therapist, physical therapist, chiropractor, etc.  Please schedule an appointment with your provider to assess and arrange for the referral.


We strive to give the highest quality of healthcare within the budget of our patients. We participate with many of the major insurance plans.  We also work with Motor Vehicle Accident (MVA) and Worker’s Compensation claims.  As insurance plans and coverages frequently change, it is very important that this information is updated and verified at each visit. At the time of service, we will notify you of any deductibles or co-insurances that may be required.

Co-Payments (or Co-pays)

Co-pays are due at the time of service upon check-in.  For patients with insurance deductibles, we require a minimum of $50 per office visit that we will apply towards your deductible, or the Full payment for Diagnostic tests done at this office. We accept cash, checks and MasterCard or Visa credit and debit cards.


We understand that our patients’ schedules change.  If you would like to re-schedule an appointment, please give us 24-hours advance notice.  A patient who misses or cancels an appointment with less than 24-hours notice will be responsible for a $50 Missed Appointment Fee, payable upon receipt (by mail), or at the next appointment.

Privacy Practices (HIPAA)

Eastside Regenerative Medical respects your privacy.  We understand that your personal health information is very sensitive.  We will not disclose your information to others except in the case of: a) continual medical care; b) patient’s written authorization; c) the law authorizes or requires us to do so.  For more details, please ask for our Notice of Privacy Practices.

We are glad that you have decided to join us, and we look forward to working together with you.  Below are a few items to review to help you become acquainted with our Health Center.  If you have any questions, please do not hesitate to contact us.


Please see our Contact page for complete directions to our clinic.

                                                     11415 SLATER AVE. NE KIRKLAND, WA 98033 | CARE@RMG.LIFE