New Patient Inquiry (No Header for Contact Us Page)

First Name

Last Name

Date of Birth

Ex. 09/09/1970

Phone

Example: 971-612-6100

Email Address

New or Current Patient?

Current Provider

Knowing your previous or current provider will help our scheduling team get you established with the right fit. Our providers often specialize in different parts of primary care such as diabetes, kidney issues, autoimmune disorders, occupational medicine.

What are you currently needing

Please note. We currently do not offer long-term chronic pain management, but are willing to facilitate referrals as needed.

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

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

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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