Whole Health Referral Needed
I need a referral for a medical or health issue
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First Name *
Last Name *
Best Email Address *
Best Contact Phone Number *
Type of issue I need a referral *
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Agreement - Release of Information:                                                                                                                              A.  I authorize the New Mexico Dental Association Foundation (NMDAF) to release information provided on this form, understanding that I may be contacted by another group or agency about the health related issues I have included on this form:                                                                        B. I understand information provided by me or others as noted above may be given only to the volunteers involved in my treatment and will be held confidential.  I authorize the program to share information with and obtain information about me with one or more health care provider (s) volunteering or participating in the program. *
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