Patient Forms

If you are a new patient, please fill the applicable forms from below and submit them to our office at least one week prior to your appointment. Forms may be emailed to: orders@trilliumnatural.com or faxed to (412) 573-8610. You may also mail the forms to: Trillium Natural Medicine, 3043 West Liberty Ave., Pittsburgh, PA 15216. If you are a new patient coming in for a fertility consult, please fill out both the Adult Patient Packet and the Fertility Healthy History. If you would prefer to have us mail you a paper copy, please let us know. Thank you!

• Adult Patient Packet
• Fertility Health History
• Pediatric Patient Packet – (birth to 5 years old)
• Pediatric Patient Packet – (6 years to 12 years old)
• Nutrition for Fertility – Please contact Trillium Natural Medicine for your password.
• Nutrition Intake Form
• Metabolic Assessment Form
• Notice of Privacy Practices – Please read this form before your first appointment. It is not necessary to print it.