New Patient Inquiry

New and prospective patients, please fill out the form below. The Dallas Family Care team is taking patient information through this form and will reach out to you to schedule an appointment once your information has been added to our system. We look forward to serving you in our local neighborhood clinic.

First Name

Last Name

Date of Birth

Ex. 09/09/1970

Phone

Example: 971-612-6100

Email Address

Current Provider

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

Reason for Changing Provider

Knowing the reason for changing your current provider will help our scheduling team find you the right fit from our provider team.

Current Need

What are you currently needing

Just Looking to Transition Care (No Rush)

Would Like Registered Soon

Would Like to Schedule an Appointment in the Next Month

Other Need (list below)

Name of Insurance

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

Member # or ID

Group Number

Address

Street Address Ex. 531 SE Clay St

City

Ex. Dallas

State

Ex. OR

Zip Code

Ex. 97338

Requesting Pain Management

Are you currently needing pain management care or are you currently on long-term pain medications / controlled substances?

Yes

Unsure

Message / Questions

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

Send me a copy of my responses

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