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A. [TM] Telemedicine OMMP Questionnaire

To prepare for this questionnaire, please have the following information ready:

​

1. IF you have any proof of support benefits such as: 

  • OHP

  • SNAP/EBT

  • Supplemental Security Income

  • Military Veteran Status

 

*Please take a picture of these documents on a WHITE BACK GROUND, STRAIGHT, and IN FOCUS and have it stored on the device you are doing this questionnaire.

psychedelics

service areas: Adair Village, Adams, Adel, Adrian, Ainsworth, Albany, Allegany, Alsea, Amity, Antelope, Arlington, Ashland, Astoria, Athena, Aumsville, Aurora, Baker City, Bandon, Banks, Barlow, Bay City, Boardman, Bonanza, Boring, Brookings, Brothers, Burns, Butte Falls, Camas Valley, Cannon Beach, Canyon City, Canyonville, Carlton, Cascade Locks, Cave Junction, Central Point, Chiloquin, Clatskanie, Coburg, Columbia City, Condon, Coos Bay, Coquille, Cornelius, Corvallis, Cottage Grove, Creswell, Culver, Dallas, Dayton, Dayton, Depoe Bay, Detroit, Donald, Drain, Dufur, Dundee, Dunes City, Durham, Eagle Point, Echo, Elgin, Elkton, Enterprise, Estacada, Eugene, Fairview, Falls City, Florence, Forest Grove, Fossil, Garibaldi, Gaston, Gates, Gervais, Gladstone, Glendale, Gold Beach, Gold Hill, Grand Ronde, Grants Pass, Grass Valley, Gresham, Halfway, Halsey, Happy Valley, Harrisburg, Heppner, Hermiston, Hillsboro, Hood River, Hubbard, Huntington, Imbler, Independence, Ione, Jacksonville, Jefferson, John Day, Johnson City, Jordan Valley, Joseph, Junction City, Keizer, King City, Klamath Falls, La Grande, La Pine, Lafayette, Lake Oswego, Lakeside, Lakeview, Lebanon, Lincoln City, Lonerock, Long Creek, Lostine, Lowell, Lyons, Madras, Malin, Maupin, McMinnville, Medford, Mill City, Milton-Freewater, Milwaukie, Mitchell, Molalla, Monmouth, Monroe, Monument, Moro, Mosier, Mount Angel, Myrtle Creek, Myrtle Point, Nehalem, Newberg, Newport, North Bend, North Plains, Nyssa, Oakland, Oakridge, Ontario, Oregon City, Pacific City, Pendleton, Philomath, Phoenix, Pilot Rock, Port Orford, Portland, Powers, Prairie City, Prineville, Rainier, Redmond, Reedsport, Riddle, Rockaway Beach, Rogue River, Roseburg, Rufus, Salem, Sandy, Scappoose, Scio, Scotts Mills, Seaside, Sheridan, Sherwood, Silverton, Sisters, Spray, Springfield, St. Helens, St. Paul, Stanfield, Stayton, Sublimity, Sutherlin, Sweet Home, Talent, Tangent, The Dalles, Tigard, Tillamook, Toledo, Tualatin, Turner, Umatilla, Union, Unity, Vale, Veneta, Vernonia, Waldport, Wallowa, Warrenton, Wasco, Waterloo, West Linn, Wheeler, White City, Willamina, Williams, Wilsonville, Winchester Bay, Winston, Wood Village, Woodburn, Yachats, Yamhill

Business Mailing Address:
GEM Clinic

PO Box 1485

Grants Pass, OR 97528
Phone: (503) 272-8781​
Fax: (503) 536-6458

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©2019 by Green Earth Medicine

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