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)

Other Need

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

Current or Past Pain Management Provider

Do you have someone that you go to specifically for pain management that is different than your primary care provider?

Yes

Pain Resource

Who do you see for Pain Management Care?

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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