Click on each PDF Logo to download each document (1 - 3). Fill them out on your computer or device.
- Clinic Forms -
Family Health & Wellness
In order for Promise Medical to administer Ketamine Muscle Injections (KMI) we need to gather some health background information from you. After the documentation is completed we will have a consultation visit for a physical screening and to review your medical history.
Phone: 385-262-4135 (Main, textable)
801-691-1448 (Alt, not textable)
Fax 801-899-7996
Services:
* cough, sore throat, fever
* sinus infection, ear infection
* COVID testing
* asthma, bronchitis, pneumonia, allergies
* kidney, bladder infections
* skin infection, cellulitis, abscess, accutane
* abdominal pain, back pain
* lacerations
* female health, testosterone replacement
* opioid addiction and suboxone treatment
* physicals (DOT, school & sports, missionary, annual)
* KETAMINE TREATMENT for depression, anxiety, PTSD & chronic pain
* any non-life threatening medical issues
Scheduling
All visits to our office should be scheduled, including same day and urgent care appointments. If you need to ask questions about your appointment or to change it, please phone us at our office (385) 262-4135.
You can also Request an Appointment Online.
Required Patient Forms
New patients should arrive 30 minutes prior to the appointment time so that we can process the information, create the medical file and place the chart in line for the designated appointment time. If you have a computer and printer, you may download the required forms (Coming Soon). Bring all medications in their original bottles (not a pill box) to your appointment. Be sure to include any over-the-counter medications you currently take.
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New Patient Information Record
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Consent to Treat Form
Office Hours
9:00 a.m. – 5:00 p.m.
Monday, Tuesday, Thursday & Friday
Our Location
We are located at 861 North 980 West Orem, UT 84057 (in front of WinCo)
You can map our location using Google Maps.
Fees & Billing
All co-pays are due at the time of your visit.
We ask that you provide your current insurance information at every visit, to make sure we have your most up to date insurance information.
You may contact our billing office with any questions (385) 262-4135
Insurance
Our office accepts most insurance plans. Call us and check if you are in out listed participating providers (Most Are). We will file all charges to your insurance plan. Any remaining balance will be your responsibility. You will also be responsible for payment should your insurance plan deny claims for any reason.
Release of Information
We are unable to release any information to anyone without your written consent on the required Alternate Contact Form. Your information is privacy-protected.