SCHEDULE NOW

PLEASE COMPLETE THE FORM BELOW. After you complete it, ONE OF OUR STAFF WILL BE IN TOUCH WITH YOU SHORTLY TO FINISH SCHEDULING.

COMPLETING THIS FORM ONLINE WILL EXPEDITE THE SCHEDULING PROCESS. IF YOU HAVE DIFFICULTY WITH THE FORM, OR PREFER TO SPEAK WITH SOMEONE, CALL OUR OFFICE AT 503.232.3215 AND WE WILL GLADLY ASSIST YOU.

Name

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Phone

(###)

###

####

Mobile Phone (for text appointment reminders)

(###)

###

####

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

YOUR VISIT

What type of service are you interested in scheduling?

Naturopathic/Functional Medicine

Acupuncture

Chiropractic

Massage

IV Nutrient Therapy

If there is a particular provider you are interested in scheduling with:

INSURANCE (if applicable)

Are you planning on utilizing insurance? If so, what is your insurance company?

Insurance Member ID:

Insurance Group Number:

Name of primary insured person:

Are you currently seeing one of our providers at another location? (requested for record release)