We currently are NOT accepting patients that have Oregon Health Plan insurance unless the patient is a sibling of an established patient.

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Thank you for choosing Salem Pediatric Clinic to be your primary medical home. Please complete the below form and our office staff will contact you to complete the registration process. Please be advised that completing this form does not indicate that a physician-patient relationship has been established. We have created this form to ensure that we can help establish care for you and your family in a timely manner. If you do not hear from our office staff within seven days please call 503-362-2481.

If you are having a medical emergency please call 911 or go to the nearest emergency room.

"*" indicates required fields

Form Completed By:*

Relationship to Patient*

Please enter your email address:*

Parent 1

Parent 1 Full Name*

Parent 1 Birthdate*

Parent 1 Address*

Parent 1 Phone*

Relationship to Patient*

Parent 2

Parent 2 Full Name*

Parent 2 Birthdate*

Parent 2 Address*

Parent 2 Phone*

Relationship to Patient*

Patient Info

Current Insurance*

Insurance ID#*

Patient 1 Full Name*

Patient 1 Address*

Patient 1 Date of Birth*

Patient 1 lives with:*

Add another patient

Patient 2 Full Name*

Patient 2 Address*

Patient 2 Date of Birth*

Patient 2 lives with:*

Add another patient

Patient 3 Full Name*

Patient 3 Address*

Patient 3 Date of Birth*

Patient 3 lives with:*

Add another patient

Patient 4 Full Name*

Patient 4 Address*

Patient 4 Date of Birth*

Patient 4 lives with:*

Appointment Details

What type of appointment do you need to schedule?*

Are all patients up to date on immunizations?*

Yes

Please note: If the patient has received immunizations outside of the state of Oregon. We will need a copy of these prior to registering the new patient.

Have all patients received the MMR immunization?*

(our policy at Salem Pediatric Clinic is that all of our patients receive the MMR immunization)

Yes

Which provider are you requesting to establish care with?*

Suzanne Bailey, MD; Kari Carstensen, MD; Rachael Hiebert, MD; Andrea Stout, MD; and Thu Vu, MD are not currently accepting new patients except for newborns.

Other:*

Comments

This field is for validation purposes and should be left unchanged.

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Parent 1

Parent 2

Patient Info

Appointment Details

SPC Welcomes Dr. Ian Straehley

Medical Chaperone

Mask Policy Update

Winter 2022-2023 Update Regarding Wait Times and Sick Visits

New Family Registration

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Parent 1

Parent 2

Patient Info

Appointment Details