South Salem Primary Care - Patient Inquiry Form

New and prospective patients, please fill out the form below. We look forward to serving you and appreciate your interest in our services.

 
 
 
 
mm/dd/yyyy
 

Example: 971-612-6100

 
 
 

Knowing your previous or current provider will help our scheduling team with transitioning your care.

 

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

 
 

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