CONTACT INFORMATION Please print clearly.
Name: Today’s date:
Street address:
City, State, Zip:
Home Phone:
Cell Phone:
Work Phone:
Email:
Which phone number would you like
us to contact you with confidential
information?
EMERGENCY CONTACT:
Name: Relationship:
Home/Cell Phone: Alternative Phone:
PERSONAL INFORMATION
Date of birth: Age: Gender: Ethnicity:
Relationship status: Married/Partnered Single Divorced Widowed Number of children:
(check one)
Occupation: Hours worked:
PCP/INSURANCE INFORMATION
Primary Care Provider: Phone number:
At this time, Minna Yoon, ND, L.Ac. of Bay Natural Medicine does not accept insurance. However,
insurance information may be required for ordering lab tests or imaging studies. If you have a PPO
plan, please fill out the following information:
Insurance Company: Primary ID:
Group number:
Insured name (self/spouse/parent/other): DOB: