Request Medical Aid in Dying Evaluation.

Please use the form below to request an appointment. Please note: Santa Fe Mobile MD does not accept any form of insurance. We use a direct pay model. Before you sign up please make sure you familiarize yourself with our pay structure!!

Patients first name (*)

Patients last name (*)

Patients Date of Birth (*)

Patients Gender at Birth (*)

Mobile Phone (*)

Home Phone (*)

Work Phone

Email (*)

Street Address (where visit will take place) (*)

Apt/Suite

City

State

Zip (*)

Preferred Physician

Date for Requested Appointment

Reason for Appointment (*)

Who is filling out form? (Name, Relationship to Patient and Mobile number)

Are you already enrolled in hospice?

If you are enrolled in hospice, Which hospice?

What is you underlying medical condition?

Any other information we should know before we set up an appointment?

I confirm that I have read, understood, and agree to abide by the Santa Fe Mobile MD Practice Policy.