Medical Appointment Request Form

1

Are you currently a resident of New Mexico?* This field is required.

YESNO

2

Do you have a signed medical record from a licensed healthcare provider for your qualifying condition?* This field is required.

YESNO

3

Which qualifying condition do you have? (Check all that apply)

Alzheimer’s Disease

Amyotrophic Lateral Sclerosis (ALS)

Anxiety Disorder

Autism Spectrum Disorder

Cancer

Crohn’s Disease

Damage to the Nervous Tissue of the Spinal Cord (with objective neurological indication of intractable spasticity)

Epilepsy/Seizure Disorder

Friedreich’s Ataxia

Glaucoma

Hepatitis C

HIV/AIDS

Hospice Care

Huntington’s disease

Inclusion Body Myositis

Inflammatory Autoimmune-mediated Arthritis

Insomnia

Intractable Nausea/Vomiting

Lewy Body Disease

Multiple Sclerosis

Obstructive Sleep Apnea

Opioid Use Disorder

Painful Peripheral Neuropathy

Parkinson’s Disease

Post-Traumatic Stress Disorder (PTSD)

Severe Anorexia/Cachexia

Severe Chronic Pain

Spasmodic Torticollis (Cervical Dystonia)

Spinal Muscular Atrophy

Ulcerative Colitis

Other

4

Full Name* This field is required.

First Name

Last Name

5

Date of Birth* This field is required.

Date

6

Phone Number* This field is required.

Please enter a valid phone number.

7

Email* This field is required.

example@example.com

8

Do you consent to being contacted by our clinic regarding your evaluation?* This field is required.

Yes

9

Payment Details

My Bag

0

Appointment FeeMedical consultation appointment fee
$130.00Edit
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