Patient Registration

Salem Clinic Registration Form

Thank you for considering Salem Clinic for your healthcare needs.
To register for primary care and/or obstetrics & gynecology, please complete the following form to the best of your abilities. Some fields and attachments are required; you will not be able to complete the registration form without those fields. Complete registration forms will be reviewed within a few days. The account holder will be contacted via the phone number provided with any questions or to confirm the registration. Appointments cannot be scheduled until registration is confirmed. For urgent care registration, please call 503-399-2424, or walk-in during urgent care hours, M-F 10-7 and weekends 10-5.

If you have government-issued insurance (Medicare, Medicaid/OHP, Tricare), you will not be able to complete registration online, please call 503-399-2424 (option1, option 1) Monday-Friday between the hours of 8:30am and 5:00pm.

To get started, please have a copy of your insurance card (both sides) and your identification (both sides) ready to attach.
Financially Responsible Party

(Account Holder) Information
Name*

First NameMiddle NameLast Name
Address (PO Box or Street)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary/Mobile Phone*
Please enter a valid phone number.
Home Phone (if applicable)
Please enter a valid phone number.
Work Phone (if applicable)
Please enter a valid phone number.

Patient Information
Name*

First NameMiddle InitialLast Name
Preferred Name/Nick Name
Date of Birth*

MonthDayYear
Date
If adult, please attach copy of patient ID

1 - Front, 2 - Back
Cancelof
Social Security Number
XX-XX-XXXX
Address (only required if different than responsible party from the previous screen)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email
example@example.com
Gender at Birth*

MaleFemale
Preferred Pronouns
Marital Status
Preferred Provider (1st Choice)*
Preferred Provider (2nd Choice)*
Current Primary Care Provider (if applicable)

First NameLast Name
Preferred Salem Clinic Provider (if known)

First NameLast Name
Employer Name (note retired, if applicable)
Occupation
Work Phone Number (if applicable)
Please enter a valid phone number.
How did you hear Salem Clinic is welcoming new patients?
We use MyChart as our patient portal for messaging, scheduling, results and more.Would you like an activation link sent to you when your registration is processed?

Insurance Information
Insurance Status
If you have government-issued insurance (Medicare, Medicaid/OHP, Tricare), you will not be able to complete registration online, please call 503-399-2424 (option1, option 1) Monday-Friday between the hours of 8:30am and 5:00pm.
Please note, self-pay patients must pay a deposit at the time of first visit. Self-pay patients cannot have other insurance; that insurance information must be provided. Do not continue as self-pay for your insurance status if you have medical insurance coverage of any kind.
Please attach copy of insurance card(s) *

1- Front (Primary), 2-Back (Primary), 3-Front (Secondary), 4-Back (Secondary)
Cancelof
Primary Insurance Information
Insurance Company Name*
Subscriber Name*

First NameLast Name
Group Number
ID Number
Subscriber's Relationship to Patient*
Subscriber's Date of Birth*

MonthDayYear
Date
Subscriber's Address (if different than patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber's Social Security Number
XXX-XX-XXXX
Secondary Insurance Information: (if applicable)
Insurance Company Name
Group Number
ID Number
Subscriber Name

First NameLast Name
Subscriber's Relationship to Patient
Subscriber's Date of Birth

MonthDayYear
Date
Subscriber's Address (if different than patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber's Social Security Number
XXX-XX-XXXX
Primary Insurance Information
Should be Empty:

Salem Clinic Registration Form