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Request An Appointment
Name
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First
Last
Phone
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Please leave us a phone number that you can pick up or that we have permission to leave a message on.
Email
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I am:
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A New Patient
A Returning Patient
Days Available for Appointment
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Select All
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Start Time for Appointment
*
8:30-10:00
10:30-11:30
12:00-1:00 PM
1:30-3:30 PM
4:00-6:00 PM
We will try to get back to you with an appointment starting in this range.
Indicate your need:
*
Motor Vehicle Accident (new)
Work Injury (new/recent)
Home/Gym/Sports Injury (new)
Everyday Pain / New or Old Issues
General Wellness (not injury or pain)
Indicate Requested Services
*
Chiropractic Treatment
Chiropractic Rehabilitation
Fitness/Sports/Diet Coaching
Massage
Specialty services like Cold Laser, Rapid Release, Kinesiotaping, Graston Myofascial Release are options available within a chiropractic appointment.
Please tell us:
*
Self-Pay Discount
Automobile Insurance (must for new car accidents)
Worker's Compensation (must for new work injuries)
Private Insurance (Providence)
Private Insurance (Blue Cross - Which one?)
Private Insurance (Kaiser)
Private Insurance (Pacific Source, Aetna, Cigna)
Private Insurance (Other - Which one?)
Medicare, Medicare Plus or Advantage
Oregon Health Plan / Care Oregon / Family Care
How'd you hear about us?
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Google
Insurance List
Walk by
Local/Neighbor
Patient referral
Doctor referral
Details, Details, Some details please!
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If you tell us a bit about your condition, we can schedule you faster and predict your benefits more properly.
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