Patient Forms

As a new patient to our office, we request the following forms. PLEASE PRINT AND COMPLETE. Completed forms can be emailed or mailed.

Health History Form, to provide the best care possible. Please complete. No disponible en español.

*** HIPAA Notice of Privacy Policy (Read Only, Not required to Print) ***

HIPAA Acknowledgement form; to verify you have access to our policy above, and understand the information provided. Please print and sign. Reconocimiento y consentimiento de HIPPA forma en español.

Our Financial Policy will explain the business billing policies. Please print and sign. Nuestra politica financiera forma en español.

The Assignment of Benefits Form will allow us to bill your insurance for payment. Please print and sign. Asignación de beneficios forma en español.

The General Consent and Rx Form will allow us to treat, and to submit electronically any prescriptions to your pharmacy. Consentimiento general forma en español.

Preparing for Surgery

Once it is determined that Surgery is required, additional information is required to authorize and prepare for treatments. Please print the Surgery Prep form 1 & Surgery Prep form 2 and return them to our surgery scheduler once completed. Fax to 503-352-1314 or email to

Additional Forms Available

The Release of Information Form will allow us to disclose information as you direct. Please fax completed form to 503-352-1314.

Please visit the Patient Portal for the following:

Medical History Questionnaires

Demographics verification and Address changes to be made.

Prescription refills.

Pharmacy Updates.

For access to the patient portal please call 503-352-1313


To schedule an appointment please call 503-352-1313Monday through Friday from 8:00 am to 5:00 pm.

Email our office for an appointment at All calls will be returned within 24 business hours.

Patient In Clinic Hours

Monday – Thursday  8:00 am to 5:00pm
Friday – 8:00 am to 2:30pm

All requests for appointments are based on availability.

Outpatient Surgery Hours

Monday – 7:30 am to 5:00 pm
Friday  – 7:30 am to 5:00 pm

Cancellation Policy

We understand that your schedule may change and that emergencies arise. If you are unable to keep your appointment, we ask that you provide us with 24 hours’ notice. Please extend us this courtesy so that other patients may be seen. Please call 503-352-1313 to cancel your appointment.

Payment Options

We strive to provide all of our patients with affordable medical care.  In order to do so, we request payment arrangements be made at the time of service.  We accept cash, debit or credit cards (MasterCard or VISA) for the convenience of our patients.  We will also bill your insurance company and assist in handling claims in every way we can, but responsibility for payment ultimately falls to the patient.

Accepted Insurance Plans

(this is just a brief list, please call us if you do not see your plan)

Private Health Insurance

  • Blue Cross Blue Shield
  • Aetna
  • Lifewise
  • First Choice Health Plan
  • United Healthcare
  • Cigna
  • Providence PPO & Preferred
  • Pacific Source
  • Moda
  • Portland Public Schools Health & Welfare
  • Healthnet

Workers' Comp Plans

  • SAIF
  • Oregon Health Systems
  • Managed Healthcare Northwest
  • Portland Police & Fire
  • Tri-Star
  • Gallagher Bassett
  • Chartis
  • Hartford WC
  • Liberty Mutual
  • Pinnacle Risk Management
  • Zurich
  • Providence MCO
  • Caremark
  • US Dept of Labor
  • ESIS
  • Coventry
  • Liberty Northwest
  • Sedgwick
  • Specialty Risk Services
  • Corvel
  • Broadspire
  • Farmers WC

Office Policies

Prescription Refills

If you require a prescription refill, please visit the Patient Portal or call your pharmacy and have them submit us the refill request via fax #503-352-1314.

Routine prescriptions refills cannot be made during evenings, weekends or holidays, so please plan accordingly and call us during a weekday two business days before your medication runs out.  We cannot call in certain prescriptions for pain medications including narcotics to pharmacies; you will be required to pick up some prescriptions at the front desk during regular business hours. In urgent cases, patients should visit the emergency room.

Outside Medical Forms, (FMLA, AFLAC, Disability, etc.)
For outside medical forms to be processed, the ORIGINAL form(s) need to be dropped off at our receptionist desk.  You will be charged a fee of $25.00 for the completion of forms such as AFLAC, FMLA, etc.  Or you may be required to schedule an appointment. Payment is due at the time that you pick-up these forms. Please allow 7-10 days for the completion of these forms. If you would like the forms mailed to you or the insurance, payment will be due prior to mailing, and we request you provide the self-addressed stamped envelope.  We do not fax or email the completed forms.

There is an additional charge of $75.00 for same day service for the completion of outside medical forms.

Make An Appointment To Come See Us

We’ll be able to diagnose your issue and get started working towards a solution that will have you better in as little time as possible.