New Patient Inquiry

If you would like to set up an initial appointment with one of our providers, please complete this form. Dr. Cooper and Kristen Rheinlander, PA-C work as a collaborative team.

If you have read about our services and feel you are a good fit, please contact the front desk directly and complete this form. Our front desk can help answer any questions and schedule your appointment. Please call us at 206-632-4575 or email us at info@coopermetabolic.com. This is a HIPAA secure form.

Note: Proof of full Covid vaccination, including booster, is required of all eligible individuals for entry into our clinic.

First Name *

Last Name *

Phone with area code *

E-mail *

Do you reside in Washington State? *

Yes

No (please list the state where you reside) No (please list the state where you reside)

If eligible, are you fully vaccinated, including booster, against Covid 19? If not, are you willing to get vaccinated since it is a requirement for entry into the clinic? *

Yes, I am fully vaccinated, including booster.

I have not received the booster but I am willing to.

I have not received the booster and I am not willing to.

No, I am not vaccinated but I am willing to.

No, I am not vaccinated and I am not willing to.

Please select the date of your first vaccine dose: * +

Please select the date of your second vaccine dose: * +

Please select the date of your first booster: * +

Please tell our providers a little bit about your reason for seeking care and your health goals. The more information you share, the better we can assess whether we can help you meet your goals! *

How did you hear about our clinic? *

(Optional) Could you provide the name of the healthcare provider (PCP, pediatrician, etc.) who referred you?

Would you like to receive updates from Dr. Cooper's nonprofit, the Diabesity Institute? *

Yes

No