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 415-721-7453 for an appointment

Complete one of these forms prior to your first visit:  

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

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, Acupuncture, or both.   New patient appointments are 60-90 minutes Follow-up appointments are 45-60 minutes

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