NEW PATIENT PAPERWORK
Before your first appointment at Bastyr University Clinic, you must complete the Patient Intake Form.
1. Download free Adobe Reader software
2. Click on the link below “Patient Intake Forms”
3. Download the PDF and save it to a designated area on your computer
4. Fill out the form and SAVE
- Patient Intake Forms (for all new patients)
Once you have completed the form, please return it to the clinic in one of the following methods:
1. Fax to us at (858) 246-9710
2. Mail them to: Bastyr University Clinic Attn: Medical Records, 4110 Sorrento Valley Blvd., San Diego, CA 92121
3. Physically bring a copy to the clinic at the address listed above
4. You may also use our patient portal (MyChart) to upload the documents. If you need to activate MyChart, please speak to a Patient Service Representative (PSR) by calling the clinic at (858) 246-9730.
· Instructions for Uploading via MyChart * this is best done on a laptop or desktop computer
1. Call the clinic at (858) 246-9730 to let the PSR know you will upload your documents via MyChart. They will send you a message to which you will reply with your uploaded form(s).
2. Log into MyChart with your user name and password.
3. Go to Messaging icon at the top, then click “Message Center.”
4. Select the message from the PSR and click “Reply.”
5. At the bottom, click “Attach an image.”
6. This will open a box for you to search for your saved form(s) and upload.
a. Note: You can only upload PDF files
b. You can click on the PDF to view and ensure it is the correct file
7. If you need to upload another form, you can select “Attach another image”
8. Once you upload all documents, click “Send”
ADDITIONAL FORMS:
- Medical Records Release Form
- Application for Income-Based Rate Adjustment
- Homeopathy General Form
- Adult Proxy Form. (For an adult patient that would like another adult to have access to their medical information, please use this form)
- Child Proxy Form (For any patients under the age of 12, a parent or legal guardian can access their MyChart account using this form)
- Permission to Treat a Minor Form (A parent/legal guardian must attend a minor’s first visit with Bastyr University Clinic. For parents or legal guardians who cannot be present for subsequent visits, please fill out this form.)