Patient Registration

Salem Clinic Registration Form

Thank you for considering Salem Clinic for your healthcare needs.
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 10 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.

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.

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