Clinic Forms

Privacy Practice Policy

Patient Initial Intake Form

Please download the Patient Initial Intake Form from our website and take the time to fill it out as completely as possible. The answers you provide will give Dr. Nguyen an understanding of you or your child as a whole person and will greatly aid in the evaluation of your health conditions. Save your completed form as a PDF by clicking the “Save” button on the form and attach it to your email to send to info@dralysa.com.

In order to save or e-mail your completed Patient Initial Intake Form please download the latest version of the Adobe Reader software by clicking on the link below and then following the directions on the Adobe website.

Download Adobe Reader

Please send the form 2 days prior to your first visit. If you should experience any problems saving or e-mailing the Patient Initial Intake Form, please print a copy and fax the form to the office at 1-866-931-0815. If you have a copy of any recent labs that would be helpful, bring those with you. Furthermore, bring in any medications, vitamins and supplements that you are currently taking.

Basic Health Insurance Questionaire – The Basic Health Insurance Questionaire form is a guide to see if your insurance company will reimburse for Naturopathic or Chinese medical care.