New Patient Interest Form | iNetMedrx2 | Las Cruces

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Call Us 575-636-2506

1635 S. Don Roser Drive Las Cruces, NM 88011

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iNetMed Rx² Inc.

Someone will contact you for further information about making an appointment within 3 business days, if not please call us at 575-636-2506

New Patient Interest Form

Please take the time to fill out the information below.

First Name:

Phone:

Birthday

Preferred Prounouns

Reason For Visit:

Psychiatric Evaluation (medication managment)

Psychological Evalutation

Neuropsychological Testing

Psychotherapy/Counseling

EEG Neurofeedback

Last Name:

Email

Current Gender Identity

Referred By:

Other reason for vist

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