Are you an existing patient? *

If you are an existing patient AND you have OHP, you don't need to fill anything out. Please treat yourself to a macaron from Naked Lemon.

Yes (please just fill out names and dates of birth)

No (please fill everything out)

Do you have Oregon Health Plan?

Yes (there is no cost to you for your services)

No (monthly subscription applies)

Parent 1 *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent 2

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Primary Phone Number *

(###)

###

####

Primary Mailing Address *

P.O. Boxes are fine :)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

May we have your consent to request and review your previous records or those of your children? *

Wohoo! Last question for now! Go get a taco. You earned it. By selecting "yes" below you are providing your consent for us to request pertinent medical records on your behalf to review and prepare to meet you. This helps us optimize the care we provide and give you a personal, effective experience. We will only request records for items which pertain to or affect the care we provide for you.

Yes, I give consent for you to request pertinent health records from my previous provider

No, I do not give my consent to request previous records.

Not applicable. There are no previous records to obtain