New Patient Scheduling Request

We look forward to assisting with your metabolic and preventive health goals.

Before completing this form, please review the information and videos on our new patient inquiry web page.

This request form is strictly for scheduling your visits/telehealth, so it's important to review the information on our website, which details the key points mentioned on this form. Please complete this form only if you are ready to schedule.

If you are not ready to schedule but have questions, please email us.

I acknowledge *

I have watched the two introductory informational videos on Cooper Center's website.

Full Name *

Please enter your date of birth * +

Email Address *

Phone Number *

MAILING Street Address *

Address Line 2

City *

State *

Zip Code *

I acknowledge *

The clinic does not bill insurance and is an out-of-network provider. Appointment fees are due at the time of service. The clinic will provide a superbill which I can submit to my insurance.

I acknowledge *

I will contact my insurance company if I have any questions regarding insurance reimbursement or lab coverage. I am aware that SPM is not responsible in any way for reimbursements or lab fees, as that is solely the patient's responsibility.

I acknowledge *

The clinic is not a Medicare provider, and my visits are not reimbursable by Medicare, so SPM will not create superbills for patients insured only by Medicare.

I acknowledge *

Kaiser HMO plans do not cover lab processing fees, so these fees will be an out-of-pocket expense for any Kaiser HMO-insured patients. SPM cannot confirm if Kaiser will reimburse for appointment charges.

I acknowledge *

The clinic's cancellation policy requires cancellation 3 business days before my appointment (clinic business days Monday - Thursday) to avoid incurring a full appointment charge.

I acknowledge *

My initial lab appointment will be at the clinic in Seattle and my provider visits will be through telemedicine.

I acknowledge *

I must be in the state of WASHINGTON during all my telehealth appointments, and this is a state regulation- not an SPM policy.

I acknowledge *

The clinic charges a specimen processing fee for labs drawn in clinic. Initial new patient labs need to be drawn in the clinic but I am free to utilize draw stations as an alternative for follow-up labs. This processing fee is $110 and is separate from my Quest testing fee billed directly to your insurance by Quest. We request that all new patients have an 'AgRP' test, which costs $250 out-of-pocket, payable to Inter Science Institute. AgRP is the most important metabolism-blocking neurotransmitter, and this information helps to guide treatment.

I acknowledge *

First appt Fee: $435 (NP/PA) OR $490 (Dr. Cooper pediatric) or $510 (Dr. Cooper adult).

I acknowledge *

Second appt Fee: to review labs and set up your initial plan: $435 (NP/PA) OR $490 (Dr. Cooper pediatric) or $510 (Dr. Cooper adult).

I acknowledge *

Routine follow-up Fee (every 2-4 months): $380 (NP/PA), $420 (Dr. Cooper)

I acknowledge *

My scheduling call is focused on scheduling my initial appointments and the scheduler is not able to answer medical questions.

Reason for Visit *

Insurance Provider (needed for quest lab orders and RX processing) *

Insurance Policy Number (Please include any prefix or suffix details. i.e. any letters or extra numbers that precede or follow the primary number.) *

Insurance Group Number *

Is this insurance a Medicare plan, or is it affiliated with Medicare in any way? *

Yes

No

Are you the primary subscriber on this insurance policy? *

Yes

No

Who is the Primary subscriber?: *

Subscriber Full Name *

Subscriber Date Of Birth: * +

Subscriber Sex: *

Subscriber Street Address (mailing) *

Subscriber Address Line 2

City *

State *

Zip Code *

Subscriber Phone Number *

I acknowledge *

All patients are required to subscribe to the secure patient portal to have HIPAA-secure access to their health records and efficient communication with all departments at SPM. This program carries a subscription fee of $69 per year, which the patient pays directly to the portal for software licensing fees. *Patients receive an activation link for the portal after scheduling the first set of new patient appointments.

I acknowledge *

I am required to keep a reliable/valid card payment method on file for all appointment charges to be posted and I will have my payment information ready during my scheduling call.

If you are ready for a scheduling call - please check Yes. You will be directed to a Calendly link to choose a time for one of our schedulers to assist you. The scheduling call will take about 15 minutes. If we are free before your scheduled time we will reach out if possible. *

Yes, I'm ready to schedule a call through Calendly to set up my new patient appointments.