Sept/Refill form (RFFT)

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.
Acute Protocol

*We send some prescriptions to mail-order pharmacies that don’t price gouge and are free from corporate pressure. This allows us to best serve patients who want these medications on hand in case of infection, but is not ideal for someone who needs medication today.

If we are your best option for obtaining the treatment you need, please proceed by filling out the intake forms and we will prioritize your registration. Please be sure to complete all registration requirements (upload or email us your ID & selfie, for example) to ensure nothing slows down your prescription.

By selecting the Acute Protocol, you will receive (2) prescriptions: the first with medications that regular pharmacies either don't carry or often refuse to fill, and the second with everything else. The first prescription will go to a low-cost mail-order compounding pharmacy and ship to your door. The second prescription will go to your local pharmacy for speed and convenience and so you have the option of using insurance.

*Exactly which medications you are prescribed will vary depending on your medical history and current medications.
COVID/Flu/RSV Prevention & Treatment Meds

You will receive two prescriptions. The first includes the medications that regular pharmacies often refuse to fill. The second includes everything else.

Some patients only want the prevention meds. But, we write both prescriptions for everyone. This ensures all our patients can begin treatment immediately if they get sick. This also ensures you won’t have to pay another consultation fee if you end up getting sick.

You do not have to fill the second prescription. Many patients notify the pharmacy not to fill the second Rx. They choose to keep it on hand to fill at the first sign of symptoms. You can also ask your pharmacy to delete one or more meds from any prescription. Only do this if you are sure they never want to use them.

The first prescription will go to a low-cost, mail-order compounding pharmacy. It ships directly to your door. We send these off-label prescriptions to reliable, independent pharmacies. They don’t price gouge and are free from corporate pressure. The second prescription will go to your local pharmacy. This is for your convenience and allows you the option of using insurance.

The Prevention Protocol dosages are lower than the acute dosages. You will receive both dosage instructions.

*Your exact prescription will vary depending on your medical history and current medications.
COVID Long Haul Syndrome Meds

*We send some prescriptions to mail-order pharmacies that don’t price gouge and are free from corporate pressure. This allows us to best serve patients who want these medications on hand in case of infection, but is not ideal for someone who needs medication today.

If we are your best option for obtaining the treatment you need, please proceed by filling out the intake forms and we will prioritize your registration. Please be sure to complete all registration requirements (upload or email us your ID & selfie, for example) to ensure nothing slows down your prescription.

You will receive two prescriptions: the first with medications that regular pharmacies either don't carry or often refuse to fill, and the second with everything else.

The first prescription will go to a low-cost mail-order compounding pharmacy and be shipped directly to your door. The second prescription will go to your local pharmacy for your convenience and so you have the option of using insurance.
You will receive two prescriptions: the first with medications that regular pharmacies either don’t carry (the correct low dosage of naltrexone) or often refuse to fill (ivermectin, hydroxychloroquine)*, and the second with everything else. The first Rx will be sent to a low-cost mail-order compounding pharmacy and shipped directly to your door. In our extensive experience, insurance will not cover the medications in the first Rx. The second prescription will go to your local pharmacy for speed and convenience and so you have the option of using insurance.
COVID/Flu/RSV Prevention & Treatment Meds + COVID Long Haul Syndrome Meds

You will receive two prescriptions: the first with medications that regular pharmacies either don't carry or often refuse to fill, and the second with everything else.

The first prescription will go to a low-cost mail-order compounding pharmacy and be shipped directly to your door. We send these off-label prescriptions to reliable, independent pharmacies that don’t price gouge and are free from corporate pressure. The second prescription will go to your local pharmacy for speed and convenience and so you have the option of using insurance.

The Prevention Protocol dosages are lower than the dosages in case of infection. You will receive both dosage instructions.

*Exactly which medications you are prescribed will vary depending on your medical history and current medications.
Comprehensive Health Screening Labs

Description: The lab tests listed below are sufficient for a comprehensive nutritional screening. They do not need to be measured all at once, but blood should be drawn for the parathyroid hormone, and 1,25(OH)2D at the same time if possible.

IMPORTANT: Fasting is required for many of these tests, but not all. Always consult the laboratory instructions for the test regarding fasting and follow them strictly. Avoid supplements the day of the test and during any longer period of fasting that might be recommended.

Warning: Any supplements containing biotin, especially doses greater than 300 micrograms per day, should be removed for four days to ensure high biotin levels do not interfere with any lab results. *

Note: The doctor's fee is not for the cost of the tests, it is just for ordering the tests and reviewing them.
Comprehensive Health Screening Labs: Description: The lab tests listed below are sufficient for a comprehensive nutritional screening. They do not need to be measured all at once, but blood should be drawn for the parathyroid hormone, and 1,25(OH)2D at the same time if possible. IMPORTANT: Fasting is required for many of these tests, but not all. Always consult the laboratory the instructions for the test regarding fasting and follow them strictly. Avoid supplements the day of the test and during any longer period of fasting that might be recommended. Warning: Any supplements containing biotin, especially doses greater than 300 micrograms per day, should be removed for four days to ensure high biotin levels do not interfere with any lab results.*

I understand
The Comprehensive Health screening includes but is not limited to the following labs:
- Complete Blood Count (CBC) (LabCorp, Quest)
- Comprehensive metabolic panel (LabCorp, Quest)
- Parathyroid Hormone (LabCorp, Quest)
- 1,25(OH)2D (LabCorp, Quest)
- Serum magnesium (LabCorp, Quest)
- RBC Magnesium
- Whole blood vitamin B1 (LabCorp)
- Whole blood vitamin B2 (LabCorp)
- Vitamin B5 (LabCorp, Quest)
- Plasma vitamin B6 (LabCorp, Quest)
- Vitamin B7 (LabCorp, Quest)
- Serum and RBC Folate (single test: LabCorp; Quest offers serum and RBC separately)
- Serum B12 (LabCorp, Quest)
- Uric Acid (LabCorp, Quest)
- Plasma ascorbate (LabCorp, Quest)
- Manganese in whole blood (LabCorp) or red blood cells (Quest)
- Plasma selenium (LabCorp)
- Iron panel (LabCorp, Quest)
- Serum transferrin (LabCorp, Quest)
- Total Glutathione (LabCorp)
- 24-hour urine iodine (LabCorp, Quest)
- Homocysteine
- Glycohemoglobin
- HS CRP
- Triglycerides
- Total Cholesterol
- LDL
- HDL
- DHEAS
- SHBG
- Free testosterone
- Cortisol
- Testosterone
- Creatine kinase
- GGT
Long Haul (COVID or Vax) Prevention OR Treatment labs

IMPORTANT: Fasting is required for many of these tests, but not all. Always consult the laboratory instructions for the test regarding fasting and follow them strictly. Avoid supplements the day of the test and during any longer period of fasting that might be recommended.

Warning: Any supplements containing biotin, especially doses greater than 300 micrograms per day, should be removed for four days to ensure high biotin levels do not interfere with any lab results. *

Note: The doctor's fee is not for the cost of the tests, it is just for ordering the tests and reviewing them.
Long Haul (COVID or Vax): Prevention OR Treatment labs IMPORTANT: Fasting is required for many of these tests, but not all. Always consult the laboratory the instructions for the test regarding fasting and follow them strictly. Avoid supplements the day of the test and during any longer period of fasting that might be recommended. Warning: Any supplements containing biotin, especially doses greater than 300 micrograms per day, should be removed for four days to ensure high biotin levels do not interfere with any lab results.*

I understand
The Long Haul (COVID or Vax) Prevention OR Treatment screening includes but is not limited to the following labs:
- Plasma zinc
- Serum copper
- Iron panel (serum iron, UIBC, TIBC, iron saturation %)
- Ferritin
- Transferrin
- CBC With Differential/Platelet
- D-Dimer
- Serum vitamin A
- 25(OH)D
- Plasma amino acids (a standalone plasma amino acid panel is sufficient, but this is often combined into other panels, such as the Genova ION or the Genova NutrEval)
- LabCorp’s ANA Profile 12
Due to the uniqueness of these labs the prescription might need to be sent to Labcorp. Please, include the Labcorp near you. Click on the following link to find the Labcorp near you: https://www.labcorp.com/labs-and-appointments-advanced-search

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.
I have a prescribing doctor who is monitoring my regular medication use.I lost my prescribing physician in the last 6 months and haven't found a new one yet.It's been more than 6 months since I had a regular prescribing doctor.
In order to prescribe your selected protocol, we require that you have seen your PCP or other regular prescribing doctor in the previous 6 months. To select from one of the other available protocols, please click the Back button below.
In order to prescribe your selected protocol, we require that you have seen your PCP or other regular prescribing doctor in the previous 6 months.

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 this consent form
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.

Telehealth Service Waiver and Limitation of Liability

By using our telehealth services, you acknowledge and agree to the following terms and conditions:

1. Scope of Service: Our telehealth consultation provides medical advice and treatment based on the information you provide during your consultation. Our medical responsibilities end once your prescription is issued or a treatment plan is provided. We are not your primary care provider (PCP), nor do we assume any ongoing responsibility for your medical care.

2. No Follow-Up: We are not obligated to follow up, call, or message you to check on your condition or progress after your consultation. It is your responsibility to seek further medical care if your condition does not improve or worsen or if you experience new or unexpected symptoms.

3. Emergency Care: If you feel that your condition is not improving or experiencing a medical emergency, you must seek immediate care at an emergency room (ER) or urgent care facility. Telehealth is not a substitute for in-person medical services, particularly in emergencies.

4. Limitations of Telehealth: Our services are limited by the nature of telemedicine. We cannot perform physical examinations, laboratory tests, or imaging, which may be necessary for diagnosing or treating certain conditions. Therefore, you agree to seek in-person medical care as needed.

5. Complications and Risks: By accepting the services, you understand that we are not responsible for any possible complications, adverse reactions, or outcomes from the prescribed treatment. All medical treatments carry risks, and it is your responsibility to monitor your condition and seek further medical attention as necessary.

6. No Ongoing Doctor-Patient Relationship: The telehealth consultation and the issuance of a prescription do not establish a long-term doctor-patient relationship. This consultation is a one-time service, and we do not assume any ongoing responsibility for your healthcare after the consultation.

7. Patient Responsibility: It is your responsibility to follow the treatment plan provided and to seek further medical care if your condition does not improve or if you experience any side effects. Our telehealth service does not include ongoing monitoring, and we will not be responsible for managing any future health concerns.

By using our telehealth service, you acknowledge that you understand and agree to these terms.
I have read and understand the above terms and conditions, and I agree to abide by them. I acknowledge that I am responsible for seeking additional medical care when necessary and that this telehealth consultation is a limited one-time service.