Appointment Request Form
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
May we text you at this number for appointment confirmations, questions or information you might need?
*
Yes
No
Yes, but I prefer email
Phone calls only, please
Gender
For medical consults, you must be physically located in Montana or Washington state for the actual consult.
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you plan to use insurance to cover the visit?
Yes
No
Insurance
What insurance do you have? Please list the plan name, subscriber if other than yourself, member ID and group number. Include primary and secondary plan information if you have both. Alternatively, you may upload an file with your card images below or use the camera option below that.
Insurance Info:
You may upload a pdf or doc file with your insurance information using the Files option below OR take photos of your insurance cards in the Take Photo sections. When taking photos, if you only have a primary plan, use the secondary spot to photograph the back of your card. If you have both a primary and secondary plan, it's okay to photograph just the fronts of your cards.
For uploading a document showing your insurance cards. Include primary and secondary if your have one.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
You may take a photo of your primary insurance card.
You may take a photo of your secondary insurance card.
Appointment Details
What date and time work best for you? Please note- you'll receive an email acknowledging your submission with your selected date and time, but final confirmation will be sent by email after your selection has been reviewed and approved.
If the above selections are not suitable, choose another date and time that will work for you. Confirmation that the appointment is approved will be sent by email soon. Please call 406-543-5444 if you do not receive confirmation within 2 business days.
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Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
What is your primary concern?
*
Cognitive Health
Long Covid/PASC
Mast Cell Activation/POTS
Gut Issues
Diabetes Prevention/Reversal
Hormones
CardioMetabolic Issues
Weight Optimization
Preventive Consult
Follow Up Visit
Other
Have you been a patient previously?
Yes
No
Other
Comments or questions:
By submitting this form you are agreeing to receive occasional emails from Carla/Health Solutions regarding practice updates, clinical reminders, educational information, and group offerings. Typically these are sent no more frequently than once or twice a month. Appointment reminders are automatically sent by email. If you don't agree to receive these emails, please call 406-543-5444 to schedule.
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