PATIENT's Full Name. (Wish to utilize a Health Insurance Plan? Enter as it appears on the Patient's insurance ID card.) *

First Name

Last Name

Phone Number *

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Date of Birth (Full DOB required for scheduling care, and insurance billing.) *

MM

DD

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Which of our Medical Services (Potentially billable to Health Insurance Plans) are you interested in? Check ALL that Apply: *

Primary Care Medicine visit with a Nurse Practitioner (Presently we are scheduling only with our Women's Healthcare Specialist)

Acupuncture: Traditional Oriental Medicine & Natural Wellness Consultation

Medical Massage Therapy

Occupational Therapy: Alleviate Pain, Improve Sleep, Optimize Work / Recreation Function, Treat Edema, &/or Injury Rehabilitation

Pregnancy Massage (Pre- and Post-Natal Bodywork)

Annual Physical Examination

School / Sports Physical

Behavioral Health: Mental and emotional balancing

Acute Care and/or Sick Visit (Note: We do NOT provide Urgent, NOR Emergency Care)

Pharmaceutical Prescriptions - Refill, New Rx, Medication Adjustment

Referral - Labwork, Imaging, Specialist

Essential Family Planning Services: Birth control pills, IUD removals, Referrals for Long-Term Procedures (Vasectomies, Tubal Ligations)

Advanced Family Planning Services: IUDs (Paraguard, Mirena, Kyleena, Skyla), Implants (Nexplanon), Diaphragms, Contraceptive Rings, etc

Hormone Balancing &/or Replacement Therapy

Prolapse Support (Urological / Vaginal) including Pessary Fittings & Cleaning

Womens' Wholistic Wellness: Balance Menses / Hormones; Promote Fertility; and/or Support through Lifespan Changes

Medical Cannabis Evaluation (Requires separate, focused FNP/PCP visit here)

Which of our exclusively SELF-PAY Wellness or Aesthetic Services (those NOT covered by insurance) are you currently interested in? Check ALL that Apply:

Botanical Facials ($99+ and Presently available ONLY in Santa Fe)

SkinPen Micro-Needling Treatments ($349+ and Presently available ONLY in Santa Fe)

Osmosis MD SkinCare Products ($59+ and Presently available ONLY in Santa Fe)

Colon Hydrotherapy / Colonics: Improve Digestion & Elimination; Treat Digestive Upset; Reduce Allergies; Improve Skin / Complexion; Alleviate Headaches ($109+ and Presently available ONLY in Santa Fe)

Food Sensitivity & Intolerance Testing / ALCAT Test ($199+)

Functional Medicine Bloodwork: Range of Cell Science Systems Testing ($199+)

Homeopathy ($109+)

To ensure appropriate care during the COVID19 Pandemic, for proper Scheduling of TeleMedicine and/or In Office Visits, please check ALL that apply to You: *

I have traveled outside of NM within the past 14 days, and I am NOT fully vaccinated against COVID19.

Within the past 14 days, I've had acute symptom(s) of: Cough, Shortness of Breath, Fever (100F or higher), Chills, Body Aches, Fatigue, or Loss of Smell / Taste.

Within the past 14 days, I have been in close personal contact with someone who recently tested COVID19 Positive.

I am Immuno-Compromised, as diagnosed by my Licensed Healthcare Practitioner, and I am NOT fully vaccinated against COVID19.

I live, or am currently staying, OUTSIDE of New Mexico.

NONE OF THE ABOVE Applies to me currently. HOWEVER, I understand that IF I select this option without complete accuracy: Clinic reserves the right to unilaterally cancel ALL of my future appointment(s).

Are you completing this Form on behalf of the Patient? (For example, a Family member.) ONLY IF so, then what is YOUR Name?

First Name

Last Name