Schedule If you would like to establish care with Dr. Lillian Chan, please complete the form belowto be added to the waiting list. Wait List New Patient Scheduling Name * First Name Last Name Date of Birth * MM DD YYYY Sex * Gender identity Email * Phone * (###) ### #### Insurance Provider * Aetna Moda PacificSource Providence Regence BCBS United OHP - Care Oregon Other N/A - cash pay Other Insurance Provider Please specify if you checked other above. Please specify secondary insurance if applicable. Insurance ID * Appointment Preference * Date and time Referred by (if applicable) Would you like to share any additional information? Reason for visit, services interested in, etc Thank you! You have been added to the wait list. We will contact you when space becomes available. Established Patient Scheduling
