Appointment Request Form

Appointment Request Form
Use this form to request an appointment for preventive (well visit) care, management of a chronic condition or both. You can request an appointments for one or more child on one or two days/times.

If you have NOT already requested Medical Records Transfer, please click here and complete that form first.

If you have an urgent need for information or to see or speak with a doctor: Call orText (503) 400-3852.

Please do not use this form for an appointment for injury or illness.

If there is a medical emergency, call 911
Your Name *

First Name Middle Name Last Name
Email
example@example.com
Phone Number *
Please enter a valid phone number.
Can you receive text messages about your request on the phone number provided?

Yes No
Which doctor do you wish to see? *

"Dr Scott" Hamblin "Dr Mark" Helm
How many children need appointments? *

1 2 3 or More

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
This process was easy to understand
This form was easy to use
This process and form was convenient for me

Appointment Information