Forms

New patient forms for Dr. Bassett

All patients must have the following forms signed and completed prior to first visit:

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New Patient Intake Form

Click to download, print, and fill out
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New Patient Intake Form - Pediatric

Click to download, print, and fill out
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Office Policy Agreement

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Notice of Patient Privacy Policy

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Insurance Registration Form

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Insurance Verification Checklist

Click to download, print, and fill out

New Patients

At this time, Dr. Bassett is accepting new patients. Please contact us at (971) 724-0949 or info@www.vitalia-pdx.com to schedule an appointment.

If you have medical records from other practitioners that would help us with your care, please download and complete the Release of Records Form.

Note: Follow-up with your provider from whom you’ve requested records to make sure they’ve been sent before your first visit. In our experience, this can sometimes be a timely process.

Vitalia Health, Portland OR

971-724-0949