Sept/General Registration

This intake form is HIPAA-compliant and your data is fully secure. Any private information shared with us is kept strictly confidential and is never shared with anyone.

For assistance with forms click "Chat With Us" in the bottom right of your screen or call us at (281) 393-8266.
Please enter your first and last name as it appears on your ID or DL:*

First NameLast Name
Please enter your date of birth: MM/DD/YYYY*

MonthDayYear
Date of Birth
Please recheck your date of birth - it looks like the year was entered wrong making you too old.
Minors may not register on their own. The parent or legal guardian of a minor must register first so that they can give consent for the minor to receive medical treatment. If you are the parent or legal guardian, and you have already registered with us, you can add a child or underage family member to your account inside the patient portal. If you are the parent or legal guardian and you are not yet registered, you may do so now.*
Name of parent or legal guardian:*

First NameLast Name
Date of birth of parent or legal guardian:*

MonthDayYear
Date of Birth
* Note: You will be asked to furnish IDs and selfies for both yourself and the minor you are registering.

This intake form is HIPAA-compliant and your data is fully secure. Any private information shared with us is kept strictly confidential and is never shared with anyone.

For assistance with forms click "Chat With Us" in the bottom right of your screen or call us at (281) 393-8266.
Patient Read and Signed the Consent
TURTLE HEALING BAND MEMBERSHIP AGREEMENT*
Patient Name:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*

Area CodePhone Number
Email:*
example@example.com
I do hereby request membership in Turtle Healing Band (“THB”) to be treated as a patient by a Tribal Provider (“TP”) licensedand approved by First Nation Medical Board (“FNMB”). With the signing of this Agreement, I/we agree that all people have a divinely-given right to choose and receive for themselves any type of healing they feel is best for their mind, body and spirit. These options include, but are not limited to, all forms of indigenous medicine (e.g., alternative, complementary, holistic, integrative, etc.) whether traditional or non-traditional, as well as conventional medicine.

In addition, I affirm and understand that: (1) THB members are protected by the First and Fourteenth Amendments to the U.S. Constitution as well as the United Nations General Assembly (Universal Declaration of Human Rights adopted at the Palais de Chailot in Paris on December 10, 1948); (2) THB is outside the jurisdiction and authority of federal, state, county, and city agencies and authorities for any and all complaints or grievances against FNMB, FNMB licensees, FNMB staff, Turtle Healing Band Clinics (“THBC”), and THBC staff; and (3) THB member records are the private property of THBClicensed facilities and are kept confidential.

I also swear under penalty of perjury that I am here solely on my behalf and not as an agent or representative for any Federal, State, County, or City Agencies, that I neither represent any Board (e.g., medical, zoning, etc.) or Licensing Agency (e.g., government, healthcare, etc.) nor am I on a mission of entrapment or investigation on behalf of these or any otheragencies, either on this or any subsequent visit(s), and I agree to pay $250,000.00 (Two Hundred Fifty Thousand Dollars and No Cents) in liquidate damages if I am found to be in violation of this covenant.
Initials*
UNDERSTANDING

I (and my family) agree to become a patient(s) and private member(s) of THB so that I/we may be entitled to receive goods and services from a TP providing service in a THBC facility. I/We further understand that it is entirely my/our own responsibility to consider the advice and recommendations offered to me/us by TPs or our fellow THB members and to educate myself/ourselves as to the possible risks and benefits of such recommendations. I/We agree to hold the tribal practitioners, healers, technicians, staff, and other THB members harmless from unintentional liability resulting from my/our indigenous healthcare, except for harm that results from criminal misconduct or gross negligence as determined by FNMB and/or defined by Crow Tribal Court. I/We hereby submit myself/ourselves to the jurisdiction of FNMB for the referral of any and all professional complaints against TPs and to submit such complaints to FNMB for dispute resolution. Further, I/We agree to submit any civil complaints against TPs to Crow Tribal Court for dispute resolution.
Initials*
NOTICE

Notice is hereby given to all persons that they may be in violation of Civil and Constitutional Rights should they receive a copy of this Agreement and then act under the color of law to intentionally interfere with the free exercise of the Rights retained by THB members under the Ninth Amendment (see Title 42, U.S.C 1983 et seq.; see also Title 18, Sec 241-42).

ANNUAL FEES
- $35.00 (Member)
- $15.00 (Member’s Spouse)
- Free (Children)
I enclose the fees required as consideration for my/our membership affiliation and agreement. I agree to pay these fees yearly, unless otherwise instructed. The term of my/our membership begins with the date of the signing of this agreement. I hereby certify, attest and warrant that I have carefully read the above and foregoing THB membership agreement and I (and my family) fully understand and agree with its terms and conditions.
Member’s Signature*

Clear
Date*

MonthDayYear
Date
Spouse’s Signature*

Clear
Date*

MonthDayYear
Date
CHILDREN
(name, age, gender)
1.
2.
3.
4.
*First Nation Medical Board (“FNMB”) d/b/a Turtle Healing Band is authorized by agreement with Crow Nation to create a Tribal Health Care Program that licenses Tribal Providers of indigenous medicine to provide indigenous healthcare services for its private THB members. Tribal Providers include allopaths (MDs), osteopaths (DOs), chiropractors (DCs), naturopaths (NDs), homeopaths (HMDs), and other healing arts (i.e., nurses, massage therapists, colontherapists, etc.). Private membership includes indigenous medicine patients, members of the Crow Nation, and Crow Nation affiliates.

After clicking COMPLETE REGISTRATION, your registration will be completed and you will be redirected to our SERVICE FORM where you will be able to complete your requests.

You will receive an email from Dr. Haider within 12-24 hours with your login information for our patient portal, where you will be able to ask questions and message with our medical team completely free.
After clicking UPDATE REGISTRATION, you will be redirected to our SERVICE FORM where you will be able to complete your service requests.
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