PATIENT AGREEMENT FUNCTIONAL FAMILY MEDICINEPatient Agreement Functional Family Medicine • December 18th, 2014 • New Mexico
THIS PATIENT AGREEMENT (“Agreement”) is entered into on , 20 , (“Effective Date”) by and between FUNCTIONAL FAMILY MEDICINE, LLC, a New Mexico limited liability company, located at 7301 Jefferson St. NE, Suite G, Albuquerque, NM 87109 (“Functional Family”), and the individual or individuals named on the appropriate Client Intake Form(s), incorporated herein by reference, with an address as enumerated on the appropriate Client Intake Form(s) (the “Patient”, without regard to whether one or more individuals are named).
