Patient Questionnaire Become a Patient Name * Email * Phone * Birth Date * Address * Who recommended you to this practice? Friend Doctor Google search Website Other Which provider would you like to see? Cindy Parks Jennifer Moss Annie Taylor Sharon Scelza Any Provider We accept the following types of insurance. We are not currently accepting Medicare, Medicare Supplements or Advantage Plan, Medicaid, or Oregon Health Plan patients due to the high volume we are currently caring for. Amy's Kitchen Cigna First Choice Health HMA MODA Primary Health Pacific Source Providence Health Plans Regence United HealthCare Private Pay/Cash If you have an insurance that is not on the above list, please add it here. Do you currently have a primary care provider? Yes No If yes, who? If you have seen any medical specialists in the past three years, please list them here: What are the primary health conditions or health challenges you are seeking help with? If you take regular prescription medications please list them here: Text What is your biggest obstacle to achieving your health goals? Check all that apply: Lack of knowledge Lack of energy Need clarity about what may be helpful Lack of money Other What primary issue would you like to address at your first visit other than establishing care? Thank you so much for reaching out. If you have any other comments, please write them here. We'll be in touch shortly. If you are human, leave this field blank. Submit
