PATIENT FORMS
On your First Visit
On your first visit to our office, you will be asked to have your new patient forms completed. You may download your patient forms below and bring your completed forms with you. If you have not done so in advance, we will provide you with the forms and have you fill them out prior to check-in. Our office will also scan your insurance card and your photo identification. In the event that you do not have a photo ID, we will take a picture of you for your chart.
New Patient Form
Dr. Mirza Patient Forms
Dr. Wallace Patient Forms
Medical Records Request Form
Testimonial Release Form
FREQUENTLY ASKED QUESTIONS
Patient FAQ
On your first visit to our office, you will be asked to have your new patient forms completed. You may download your patient forms below and bring your completed forms with you. If you have not done so in advance, we will provide you with the forms and have you fill them out prior to check-in. Our office will also scan your insurance card and your photo identification. In the event that you do not have a photo ID, we will take a picture of you for your chart.
Appointment Duration
Our office makes every effort possible to see patients in a timely manner. Due to the nature of our practice, emergent circumstances, and complex problems, there may be delays. Please plan for up to several hours for your appointment with our clinic.
Copay
Please bring your copay with you to the visit, if applicable. Please note, we are a specialty clinic and select insurance plans may have a specialist copay that is different than your regular office visit copay. Please contact your insurance for further information.
Physician Referrals
If you have received a referral from your primary care physician, please have it faxed directly to our office, 877-533-6717, or bring it with you at the time of your visit. If you do not know if a referral is required for you to see a specialist, please inquire with your insurance provider before scheduling an appointment.
Please note a referral from your primary care physician does not guarantee an appointment; a medical staff member will contact you after we have received the referral and medical documentation to inform you if an appointment can be scheduled.
Insurance
Although we are on many insurance plans, there are instances when we may not be part of your particular plan. Please make sure you contact your insurance company to double-check that we are within your insurance network. If you believe you are a surgical candidate, please contact your insurance company to verify that the hospitals we work with are also covered by your plan. (Inquire with our office staff about our comprehensive list of facilities.)
Pay Your Bill
Payment on your bill can be made securely through our Patient Portal or as a Guest (no login required). If you prefer other options; it can be mailed to our office, accepted over the phone with our billing staff at 503-850-9940, or made in person at our clinic. We accept cash, card, and check. Please mail payments to 4103 Mercantile Drive, Lake Oswego, OR 97035.
How can I get a copy of my imaging?
You can request a CD copy of your imaging through our website. Please submit the form along with a $5.00 processing fee and our staff can mail you a copy of the images you need. Copies can also be picked up at our office the day after a request is received.
How can I make a copy of my medical records?
In order to obtain your medical records, you must fill out a HIPAA compliant Medical Records Request Form and return it to our office for processing. Please make sure you fill it out completely. If you are having the records sent to a direct location, make sure to fill out the mailing address completely. There may be a fee for this service. The form can be returned to our office by mail or faxed to us at (503) 850-6709.
