Become a member of our practice

Here's How You Do It

1.  Click on the "Membership Request Form" button. 

      This is where you'll fill in all the basic information for each member that you are signing up. 

      You have the ability to request membership for up to six (6) members of your family online. 

      You'll need to contact us if you need to sign up more than that.

       (*while filling out your form  you can save your progress and then return to finish filling out your form

          at a later time.  If you need to log back into your form click the link near the bottom of this page)

 

2.  Fill out your request form and submit it. 

     After you've submitted your Membership Request Form and received your "Successfull Submission" 

     confirmation, we'll contact you to schedule an appointment.  During this appointment we'll answer

     any additional questions you may have and finalize the necessary paperwork. 

     All required fees will be due at this time.

 

3.  Start enjoying excellent care from your new Primary Care Provider!

What if I have trouble doing this online?

Technology can be an amazing tool, however, sometimes it doesn't work as well as we'd like it to.  If you're having trouble filling out the online forms feel free to give us a call at 575-689-8233.  We can provide you with all the forms in our office and set you up with an appointment.  You can take the forms with you and fill them out at home.  Then, bring the forms with you when you arrive for your scheduled appointment.  We'll go over any questions you may have and finalize the necessary paperwork.  All required fees are due at that time.

Mobile Users

Membership Request Form

Click to log back in to a saved form

© 2014 by ALLIED Health & Wellness, LLC