Patient Forms

At your first appointment, you will need a completed patient information and health history form. It is helpful if you complete these in advance, and bring along copies of previous tests, lab results, and the names of medications or natural supplements you are currently taking.

Please fill out the patient intake forms linked below and submit them to Bastyr University Clinic.

Download Intake Form

After completing the form, return it to the clinic using one of these methods:

Email forms to us at bucpatientcontact@bastyr.edu
Fax forms to us at (858) 246-9710.
Mail forms to Bastyr University Clinic Attn: Medical Records, 4110 Sorrento Valley Blvd., San Diego, CA 92121
Physically bring a copy to the clinic at the address listed above.
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.

Specific Forms and Instructions

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).
Log into MyChart with your username and password (call (858)246-9730 to sign up).
Go to Messaging icon at the top, then click “Message Center.”
Select the message from the PSR and click “Reply.”
At the bottom, click “Attach an image.”
This will open a box for you to search for your saved form(s) and upload.
Note: You can only upload PDF files
You can click on the PDF to view and ensure it is the correct file
If you need to upload another form, you can select “Attach another image”
Once you upload all documents, click “Send”

Medical Records Release Form

Nutrition Assessment Form

Individualize Multi-purpose Patient Questionnaire

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.)

Adult Proxy Form (For any patient 12 and older that would like a parent or legal guardian can access their MyChart account using 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)

Pediatric Intake Form (for patients 12 and under)

Adolescent Intake Form (for patients 13 to 18 years of age)

Homeopathy General Form

Application for Income-Based Rate Adjustment

The counseling department would like to get to know you before your first visit. After you’ve scheduled your first visit, fill out these counseling intake forms and send them to bucpatientcontact@bastyr.edu. You may also bring your forms with you to your first visit.

Counseling Intake Forms

IV Consent Form

high angle close up of person holding pills and vitamins in hand

Shop Natural Medicine

The clinic offers teas and tinctures as well as an online store to purchase supplements.

What to expect during your appointment

During your appointment, a team of a clinical supervisor and advanced-level students meet you, learn about your history, and combine the wisdom and cutting-edge knowledge of the full team to create a care plan for optimal health.