Prospective Patient Information Form

Please correct the errors described below.

Name you go by

Legal First Name

Legal Last Name

Pronouns

Date of Birth

Email address

State of Residence Note: We are only able to provide medical care to those physically located in the states of Oregon & Washington due to licensing laws. If you live in another state we'd still love to hear from you as Tasha may be licensed elsewhere in the future & currently provides some educational consulting services outside of OR & WA.

Oregon

Washington

Other

if other please list below

Health Insurance Type Note: We are out of network with all insurance companies other than two Oregon medicaid plans (Care Oregon & Yamhill Community Care)

Commercial

Medicare

(Including advantage plans)

Oregon Medicaid - Care Oregon

Oregon Medicaid - Yamhill

Oregon Medicaid - Other

(e.g. Pacific Source, OHSU, Trillium, Kaiser OHP plans)

Washington Medicaid

(Apple Health, Molina Medicaid, etc)

I don't have health insurance

I would like to

Schedule a free 15 minute info call to learn more & make sure we are a good fit

Schedule a new patient appointment

Other (please specify below)

How did you hear about us?

Message

Additional information you'd like to share

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