Please contact our office manager at (360)
After contacting our office, we may ask
you to complete the patient questionnaire. (Please note: you
do not need to fill in the
patient questionnaire and other forms until you are instructed.)
Please print and
complete the patient questionnaire and return it
to our office by fax [ 206-202-1985 ] or mail to [ P.O.Box 12257, Olympia WA 98508 ] .
Our office will review the patient questionnaire
to be sure that we are an appropriate resource. Our office will
contact you for further instructions after we review the questionnaire.
- Patient Questionnaire (your past and present
history) [ Download ]
When we are the appropriate resource, the
remainder of the forms can then be completed and the patient
will be scheduled.
- Cancellation Policy [ Download ]
- Practice Policy [ Download ]
- Authorization to Exchange Healthcare Information
- This form will allow us to communicate with your primary
care physician or counselor. Be sure to check the type of
information you want exchanged. [ Download ]
- Consultation Referral Request Form - Please
be sure that you have the appropriate written referral from
your primary care provider. Please fax the referral to us
at 360-545-3416 prior to scheduling your first appointment.
[ Download ]
- Patient Consent Form [ Download ]
- Demographic Information [ Download ]
- A copy of your insurance card (front and
*You can make your time
with Dr. States and his associates more valuable by completing
critical information before you come to your appointment.
Please also read the following
Please bring copies
[not originals] of recent labs, x-ray reports, school
testing or any other information you think is relevant to your
You should arrive 20 minutes before your
will be canceled if we do not receive all paper work 72 hours
before your appointment.
*All forms require Adobe
Acrobat Reader that you can download by clicking on this