Selah Medical Center
Selah Medical Center
(509) 697-8008
9 E. 1st Ave, Ste 4
HomeSelah Medical Center
New Patient Inquiry
To be considered to be accepted as a new patient please fill out this short form. We will evaluate and contact you with in 24-48 hours.
Name:
What do you need to be seen for?
Additional Comments:
Phone number:
Email:
Are you currently insured?:
If YES, type of insurance:
*** We currently do not accept an patients with CHPW, Coordinated Care, Molina, Amerigroup or Group Health
Is the reason for visit work related?
Chonic Medical problems?
Is the reason for the visit part of a motor vehicle claim?
Have you seen any other medical provider in the last 12 months?
If so, who? :
Why are you wanting to transfer care?
Current medications:
When was your last visit?
Referred to Selah Medical Center by :
Date of Birth:
