Appointment Request Posted on February 27, 2026 by Oregon Ear, Nose & Throat Center Appointment Request Step 1 of 3 33% Our online form is confidential and secure. We value your privacy, and will not sell your email to any third party. This will be used as a method of contact only. By completing this form you acknowledge that Oregon ENT Center will use this information for scheduling and account creation purposes. Disclaimer – This system is for nonemergency requests. *If you are experiencing an emergency, please proceed to the closest emergency room or dial 911. For NEW PATIENTS: You will need your insurance information to schedule. If your insurance requires a referral, please confirm that your primary care provider has faxed the referral. The appointment request form typically takes less than 3 minutes to complete. If you have questions for your provider that are not scheduling related, please use our Patient Portal or call the office 541-779-7331. First Name(Required) Last Name Patient Date of Birth(Required) Month Day Year Patient Gender(Required) MaleFemaleOtherPrefer to not disclose Patient Phone Number Is this a cell phone number? Yes By providing your cell number, you consent to receive informational SMS messages from Oregon ENT. Message and data rates may apply. You may unsubscribe any time by replying OPTOUT to any message. Email (appointment details will be sent to this email)(Required) Enter Email Confirm Email By providing your email, you consent to receive informational email messages from Oregon ENT. Message and data rates may apply. You may unsubscribe any time by replying OPTOUT to any message. Are you making this appointment for someone other than yourself such as a child or dependent? Yes Requestor's Name(Required) Requestor's Phone Number(Required) By providing your cell number, you consent to receive informational SMS messages from Oregon ENT. Message and data rates may apply. You may unsubscribe any time by replying OPTOUT to any message. Relationship to patient: Parent, Spouse, Friend, Caretaker etc(Required) Have you had an appointment with an Oregon ENT provider in the past three years?(Required) Yes No – New Patient Patient Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Information(Required) Upload picture Manually enter insurance information Would you like to upload a copy of your card(s) (front and back) or enter the information manually? Please upload a picture of the front and back of your insurance card(Required) Drop files here or Select files Max. file size: 64 MB, Max. files: 4. Insurance Information(Required) Insurance Company Member ID Group ID Are you the primary policy holder?(Required) Yes No Primary Policy Holder Information(Required) Name as it appears on card Policy holder’s Date of Birth Do you have a secondary Insurance Policy?(Required) Yes No Secondary Insurance Information(Required) Secondary Insurance Company Member ID Group ID Were you referred by your primary care provider?(Required) Yes No Referring Provider Information(Required) Provider Name Provider Phone Number Please provide your pharmacy information Pharmacy Name Pharmacy phone number or location Reason for visit(Required) AllergiesCoughCT scan *requires current order from providerDifficulty SwallowingDizziness/Balance IssuesDermatologyEar CongestionEar Pain/InfectionEar Wax/CleaningFacial PlasticsHearing LossHoarsenessNeck Mass/LumpNose Bleed – for uncontrolled bleeding proceed to ERPre-opPost-opRefluxSinus InfectionSleep ApneaSnoringSore ThroatSpeech/Language DisorderTest ResultsThyroid IssuesTinnitus/Ringing in the earVoice IssuesOther Please select the primary reason you are being seen. Please select one from the drop down list Please describe other reason(Required) Please check any recent testing related to this condition not performed at Oregon ENT (optional): CT Scan MRI Xray Ultrasound Sleep Study Swallowing Study (Barium Swallow) Audiogram (Hearing Test) Allergy Testing Lab – Blood Test Lab – Culture Lab – Pathology Please note where the CT was done so we may request results Facility Name Facility Phone Number or Location Please note where the MRI was done so we may request results Facility Name Facility Phone Number or Location Please note where the Xray was done so we may request results Facility Name Facility Phone Number or Location Please note where the Ultrasound was done so we may request results Facility Name Facility Phone Number or Location Please note where the Sleep Study was done so we may request results Facility Name Facility Phone Number or Location Please note where the Swallowing Study was done so we may request results Facility Name Facility Phone Number or Location Please note where the Allergy test was done so we may request results Facility Name Facility Phone Number or Location Please note where the Hearing Test was done so we may request results Facility Name Facility Phone Number or Location Please note where the Lab Blood Test was done so we may request results Facility Name Facility Phone Number or Location Please note where the Culture was done so we may request results Facility Name Facility Phone Number or Location Please note where the Pathology was done so we may request results Facility Name Facility Phone Number or Location Appointment Day/Time Selection(Required) First Available Monday Tuesday Wednesday Thursday Friday 1st choice of day (may select more than one) Preferred time on Monday(Required) Morning Afternoon No preference Preferred time on Tuesday(Required) Morning Afternoon No preference Preferred time on Wednesday(Required) Morning Afternoon No preference Preferred time on Thursday(Required) Morning Afternoon No preference Preferred time on Friday(Required) Morning Afternoon No preference CT Appointment Time Selection(Required) morning afternoon no preference CT Scans are only performed on Tuesday or Wednesday
