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?

By clicking here I confirm that I have read, understood and agree with the Practice Policy of Santa Fe Mobile MD

Summary

Service Type
Medical Aid in Dying (MAID) Services

Provider Name
Santa Fe Mobile MD, Telephone No.505-386-1380

Area
Santa Fe, NM, United States
Description
Complete the evaluation form to request Medical Aid in Dying (MAID) services with Santa Fe Mobile MD, ensuring respectful and professional end-of-life care.