Schedule If you would like to establish care with Dr. Lillian Chan, please complete the form belowto be added to the waitlist. Waitlist 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 I prefer email communication for scheduling I prefer text communication for scheduling If yes to text messaging, I agree to receive text messages from this company and understand that message frequency varies and message rates may apply. I understand that I may opt-out by replying with “Stop” at anytime I choose to stop getting messages and I may reply “Help” for assistance. I agree with Privacy Policy and TOS (can view under Resources section) Thank you! You have been added to the wait list. We will contact you when space becomes available. Established Patient Scheduling
