Appointment Request Form
Full Name
*
Date of birth
*
Phone Number
*
Email
*
Address
*
Gender
*
Male
Female
Others
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Are you Referral ?
*
Yes
No
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Referred Date
*
PCP Name
*
Upload Referral Letter
Need to get it from referral PCP
Initial Consultation Type:
*
Office Visit
Tele Visit
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Preferred Location
*
Vancouver
Longview
Bellevue
Portland
Beaverton
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Do you currently have active insurance coverage?
*
Insurance Status
Yes
Cash Pay
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Please provide your current insurance information
*
Insurance Name
Insurance ID
Upload Insurance Card (Front)
Front of Insurance Card
Upload Insurance Card (Back)
Back of Insurance Card
Submit Form
Visit
Columbia Allergy
for more information