Name
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Email
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Phone Number
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Format: (000) 000-0000.
Address
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City
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I am a patient
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I am a Healthcare Provider
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Where in New Mexico did the Doctor Practice?
What Happened? Please share your story. What barriers did you or a loved one face when trying to get care? What Impact did it have on your health or your life?
What impact did their departure have on their patients or community?
Share your thoughts and experiences
When did this happen?
Where did this happen (clinic, hospital, city, etc.)?
How did it make you feel? What do you want others to know?
Would you be willing to speak with someone from out team for a follow-up
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Maybe Contact Me first
May we use your story (anoymized and/or with your permission) in blog posts, public awarness Campaigns or advocacy materials to help change policy in New Mexico?
Yes, you may share my story and use my name
Yes, you may share my story, but please keep it anonymous.
No, please do not share my story
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