Forms & Policies

To be completed by a parent or guardian. A corresponding Teacher version should also be completed and returned to the clinic.

To be completed by a parent or guardian. A corresponding Teacher version should also be completed and returned to the clinic.

To be completed by a parent or guardian. A corresponding Teacher version should also be completed and returned to the clinic.

To be completed by a parent or guardian. A corresponding Teacher version should also be completed and returned to the clinic.

To be completed by your child's teacher and returned directly to the clinic. Please coordinate with the parent to ensure both the Parent and Teacher versions are submitted together.

To be completed by your child's teacher and returned directly to the clinic. Please coordinate with the parent to ensure both the Parent and Teacher versions are submitted together.

Download, complete, and return this form to our business office to apply for financial assistance. Contact our billing team at 503-535-1458 with any questions.

This is an opt-out form, not a required consent. Review the notification statement and complete only if you wish to opt out of participation in genetic research.

Reference this list to confirm your insurance plan is accepted. If your plan is not listed, call our billing team at 503-535-1458 to verify coverage before your visit.

To be completed by a parent or guardian. A separate Teacher version must also be completed by your child's teacher and returned to the clinic before the assessment can be reviewed.

To be completed by a parent or guardian. A separate Teacher version must also be completed by your child's teacher and returned to the clinic before the assessment can be reviewed.

To be completed by your child's teacher and returned directly to the clinic. Please coordinate with the parent to ensure both the Parent and Teacher versions are submitted together.

Applies to self-pay patients only (those without insurance or not using insurance). Our office will contact you 3 business days before your appointment with a cost estimate. Call 503-535-1458 with any questions prior to your visit.

Reference this guide to understand what is and is not covered as preventive care during a well-child visit. Addressing a separate illness or managing an existing condition during the same visit may be billed separately.

Reference this guide to understand what is and is not covered as preventive care during a well-child visit. Addressing a separate illness or managing an existing condition during the same visit may be billed separately.

Complete Part 1 in full before submitting. Any 'yes' answers require a brief written explanation. Include your child's name and date of birth, your phone number, preferred return method (fax, mail, front desk pickup, or MyChart), and when the form is due. Please allow 2–3 business days for completion. Important: if your child's most recent physical was more than 2 years ago, we are unable to sign the form.