Patient Forms

“My religion is love and service.” Amma

Dr. Yezman, ND, LAc is currently seeing patients at:

Naturopathic Optimal Wellness
712 D St, Suite B
San Rafael, CA 94901
Phone: 415-721-7453

Call for an appointment

We offer our clinic forms online for patient’s convenience. They usually take 15-45 minutes to complete, depending on how much time you want to spend. You can either fill out these forms online, which will be sent directly to me; or download and print out the forms, complete them, and bring them with you to your appointment. If you are unable to do either of these, please let me know ahead of time and we will make other arrangements. You can always arrive at your appointment 15-20 minutes early, and complete the forms at our office.

Complete one of these forms prior to your first visit:  

Online Naturopathic New Patient Intake Form  for adults.

Online Naturopathic Child New Patient Intake Form for patients under the age of 18.

Online Legal Only Form

Printable Naturopathic New Patient Intake Form for adults.

Printable Naturopathic Child New Patient Intake Form for patients under the age of 18.

Printable Legal Only Form

Online Acupuncture New Patient Intake Form for adults. Available soon, for now use printable version below.

Online Acupuncture Child New Patient Intake Form for patients under 18.  Available soon, use printable version below.

Printable Acupuncture New Patient Intake Form for adults.

Printable Acupuncture Child New Patient Intake Form for patients under 18.

We do not bill insurance, however; we will provide the forms you need to submit to your insurance company for out-of-network reimbursement.

Complete this form:

Insurance-Verification-Form  The rates or percentages will be out-of-network.

New patient appointments may include: Naturopathic services, Acupressure, or both.   New patient appointments are 60-90 minutes Follow-up appointments are 45-60 minutes

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