Reconstructed Wellness- Salem

Reconstructed Wellness is excited to expand to offer services in the Salem community. To get started, please complete the form below. This will allow our staff to build your profile and expedite the scheduling process over the phone.

We will reach out to you shortly after receiving your completed form. Please contact our Portland office with any questions at 503-232-3215

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Email

Phone

(###)

###

####

Street Address

City

State

ZIP

Insurance carrier (In-network with most commercial plans)

Insurance ID Number

Insurance Group Number

Additional Comments (feel free to let us anything you’d like before we contact you to schedule)