Nutrition Services: Request an Appointment with Jordan Fuentes

YOUR INFORMATION

First Name *

Last Name *

Address *

City *

State *

Zip *

Phone *

Email *

Preferred Contact Method *

Date of Birth *

MM/DD/YYYY

Insurance *

Are you a new or existing patient? *

New patient

Existing patient

NOTE: If you are a new patient, you must have a referral before we can schedule you for an appointment. If you do not have a referral, we ask that you contact your primary care provider's office to send us a referral. If you have any questions please contact the clinic at 575.746.3119. Thank you!

What is the reason for your visit? *

What is the reason for your visit?

Choose your preferred location

Artesia

Carlsbad

No preferenceNo preference

YOUR APPOINTMENT PREFERENCES

Which time(s) of the day would you prefer your appointment? (Check all that apply.) *

Morning (8:00 to 12:00 p.m.)

Afternoon (1:00 to 4:00 p.m.)

Which day(s) of the week would you prefer your appointment? (Check all that apply.) *

Please provide any additional details about your request, including referral information.

Consent Form *

I acknowledge that this appointment request form requires me to provide protected health information (PHI), which will be used to schedule an appointment at Artesia General Hospital. By submitting this form, I consent to this information being disclosed to the scheduling office, as well as receiving notifications via my requested communication method for scheduling purposes. If email is my preferred method, I understand I may receive unencrypted emails from a scheduler that may contain PHI, such as my name and the type of appointment I have requested.

Home

Online Appointment Request – Nutrition Service and Diabetes Education

Online Appointment Request – Nutrition Service and Diabetes Education

Online Appointment Request – Nutrition Service and Diabetes Education

YOUR INFORMATION

NOTE: If you are a new patient, you must have a referral before we can schedule you for an appointment. If you do not have a referral, we ask that you contact your primary care provider's office to send us a referral. If you have any questions please contact the clinic at 575.746.3119. Thank you!

YOUR APPOINTMENT PREFERENCES

Physicians & Providers

Jordan Fuentes, RDN

Nutrition Services

Locations & Hours

Home Online Appointment Request – Nutrition Service and Diabetes Education Online Appointment Request – Nutrition Service and Diabetes Education

Online Appointment Request – Nutrition Service and Diabetes Education

YOUR INFORMATION

NOTE: If you are a new patient, you must have a referral before we can schedule you for an appointment. If you do not have a referral, we ask that you contact your primary care provider's office to send us a referral. If you have any questions please contact the clinic at 575.746.3119. Thank you!

YOUR APPOINTMENT PREFERENCES

Physicians & Providers

Jordan Fuentes, RDN

Nutrition Services

Locations & Hours

Home

Online Appointment Request – Nutrition Service and Diabetes Education

Online Appointment Request – Nutrition Service and Diabetes Education