If you need a more accessible version of this website, click this button on the right. Switch to Accessible Site

WARNING

You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]

541-726-2129

In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Emergency Contact Information

Purpose Of This Visit

Reason for this visit

Insurance Information

*If an auto accident, please provide:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

Sign up using the form below or call 541-726-2129.

Office Hours

DayMorningAfternoon
Monday9:00am5:30pm
Tuesday9:00am12:30pm
Wednesday9:00am5:30pm
Thursday9:00am5:30pm
Friday9:00am12:30pm
SaturdayClosedClosed
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9:00am 9:00am 9:00am 9:00am 9:00am Closed Closed
5:30pm 12:30pm 5:30pm 5:30pm 12:30pm Closed Closed

What can we help you find?