Northwest Medical Associates - Patient Inquiry Form

First Name*

Last Name*

Phone*

Example: 971-612-6100

Email Address*

If Other Subject

If your subject is not listed above, please list below.

Date of Birth*

Reason for Visit*

Name of Insurance*

Please indicate the name of your insurance Examples: Pacific Source, United Health Care (UHC), Providence, Atrio, PEBB

Type of Insurance*

Please indicate the type of insurance plan you have with the above listed Insurance Company

Select or enter value

Other Insurance

Member # or ID*

Message / Questions

Please list any questions or information you would like to share with our team.

If Other

If how you found us is not listed above, please list below.

Thank you for being a valued patient

If you are an established patient and you are looking to send a message to your care team. Please use the Patient Portal or call the clinic at (360) 254-8025.

Thank you!

Northwest Medical Associates - Praxis Health