Good Fit Form

Let’s make sure we are a good fit moving forward! Please first review the FAQ page and then fill out the following Good Fit Form. Information on pricing is also on the FAQ page. We will review your submitted form and get back to you in the next few days. If it looks like we are a good fit, you will receive an email with some date/time options to set up your New Patient Appointment. Please make sure you check your Spam Folder as well in the next few days.

First Name *

Last Name *

How old are you? *

What is your email address? *

What is your phone number? (Mobile/cell phone is best) *

Angela Thompson, APRN is licensed in Utah and Idaho. What is your Utah or Idaho zip code? *

How did you learn about Angela Thompson, APRN/Matriarch Health and Wellness? *

Please tell us about your health journey and top wellness goals. If you had a magic wand, what would life look like? *

I have thoroughly reviewed this website and I am familiar with the FAQ page (matriarchhealth.com/faqs) including pricing for services. I also understand that Angela Thompson's practice is limited to female patients. *

I understand that Matriarch Health and Wellness is not contracted with any insurance and that fees are due at the time of service. I will be provided with a Superbill (detailed receipt) with appropriate coding that I may submit to my insurance for possible reimbursement. Note: Medicare and Medicaid do not reimburse any patients for any out-of-network services. *

I understand that I should continue to maintain a relationship with my primary care provider as Angela Thompson, APRN does not provide primary care services (e.g. Well Woman Exams (“yearly exams”) or after-hours/weekend call service). *

Do you have Medicare or Medicaid insurance? *

Any other specific questions?

Phone

Thanks! We will be in touch soon. Please be sure to check your Spam Folder! 🙂

“The first wealth is health”
– Ralph Waldo Emerson