Get Started With Enso

If you are interested in becoming a member with Enso Direct Care, please submit the from below.

Patient Information Form

We will review your submission within 2-3 business days then contact you by phone or email. All information is kept strictly confidential according to HIPAA guidelines.

Head of household or primary contact w/ name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Do you have any family members that are current members of Enso?

Yes

Please list the names and ages of any family members that are applying for membership with you.

Family Members and Corresponding Date of Birth

How’d you find Enso?

If you were referred by a current patient, please give them credit here!

Please list any previous medical history, including diagnoses, surgeries, or conditions, even those not currently medically managed.

Please list all current medications, including over the counter medications and supplements.

In the last 12 months, have you been prescribed any controlled substances such as testosterone, phentermine, tramadol, or Adderall?

Yes

Are you a prior patient of Dr. Faglie, Casey, or Kelsey?

Yes

If not, who was your last Primary Care Provider?

Do you have insurance through your employer, the market place, Medicare, or Medicaid?

Yes

Get Started With Enso

Patient Information Form

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