Registration for Qliance

To register, please download and save this Registration Packet.

Once completed, fax it to us at 206-381-3035.

Rates:

Note:  Your monthly charge must be paid by credit card.  Your total charge will include a one-time $99.00 registration fee.
For specific details, please read our Privacy Policy and Terms and Conditions.

Your membership is effective the first day of the month following receipt of registration.

In order to give you the best service, please print, fill out and bring the following forms to your first appointment:

Adult Health History
Child Medical Health History
Medical Records Transfer
Account Update Form
Privacy Form
Email Communication Form
Discontinue Service Form
Controlled Substance Policy