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(541) 677-6116 Fax: (541) 957-5181
3369 NE Stephens St, Suite 100 Roseburg, OR 97470 | Office Hours

New Patient Application


If you are interested in joining our practice, please fill out the form below. Applications are handled on a case by case basis. Please also see the "Are We a Good Fit?" page to ensure that you are aware of the details of our practice. 

Please fill out all fields to the best of your ability. 

If we are able to accommodate your child(ren), we will contact you to set up an appointment to establish care. Be aware that submitting the application in no way guarantees a spot in the practice.

Please do not call the office to check on the status of your application.

For expecting mothers and newbornsPlease do not fill out this application. To establish care for a newborn, you must come into the office and fill out a Pre-natal form. 

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North River Pediatrics
3369 NE Stephens St Suite 100 | Roseburg, OR 97470 |
(541) 677-6116 | Fax: (541) 957-5181 | DIRECTIONS