Thank you for your interest in working together with us! Please use the form to send us a new patient request. New Patient Inquiries Affirmed Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone (###) ### #### Insurance? * OHP CareOregon OHP Pacific Source OHP Providence OHP Open Card Blue Cross Blue Shield (BCBS) Aetna Providence Health Plan Cigna UnitedHealthcare PacificSource Health Plan Yamhill Community Care My insurance is not listed I don't have insurance Name on insurance card / Current legal name * Insurance ID / Group number, if known Message * A little bit about who you are and what you are looking for is much appreciated. How did you hear about us? * Thank you!We look forward to working together with you. Request an appointment.