Take this important step toward healing.

If you allow us the opportunity, we will be dedicated to your health now and in the future. We can provide as much or as little treatment, information, and encouragement as you require. And, for whatever we can't do, we will help you find someone who can.

Become a PATIENT

Fill out the form below so we can review the details and have a staff member call when we have everything ready to schedule your first appointment. Or, call (503) 257-3377 to discuss your health concern, insurance coverage or other payment options, or to answer any other questions you may have. Be sure to find us here before your first appointment.

Name

First Name

Last Name

Phone

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Email Address

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Referral

How did you hear about us?

Type of Injury / Payment

Please provide the information listed beside your selection in the Other Information section below. We understand that you may not yet have all of the requested information or that some may not apply to you. Provide whatever you do have, so that we may best determine our ability to see you and get you scheduled. A staff member may contact you if they have any questions.

Automobile Accident - your insurance carrier, name of insured, date of injury, claim #, policy #, adjuster's name and phone #, attorney's name and phone #, and if you were seen elsewhere and have any X-rays, CTs, or MRIs relating to this accident (bring these with you if you have them).

Work Injury - name of worker's compensation carrier, date of injury, claim #, name of MCO (managed care organization), if claim is accepted or denied, name of referring physician and phone #, who else you have seen for this injury, attorney's name and phone #, do you have any X-rays, CTs, or MRIs (bring these with you if you have them).

Private Insurance - please provide name of insurance, phone #, your date of birth, ID #, group # (please bring a copy of your card; most plans require a co-pay at the time of your visit).

Cash/Card - no verification required, but you are expected to pay at the time of your visit.

Other Information

Please provide any available information requested above, your preferences for scheduling, or any other information you wish to share relating to your injury or condition.