South Salem Primary Care - Patient Inquiry Form

First Name

Last Name

Date of Birth

mm/dd/yyyy

Phone

Example: 971-612-6100

Email Address

Reason for Appointment

Current Provider

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

Name of Insurance

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

Member # or ID

Message / Questions

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

Send me a copy of my responses