Request an EMT Follow-Up Visit - La Madera Fire District

Request a follow-up visit from a local EMT.

Would a conversation at home help you or someone you support? Ask the La Madera team to call you about a non-emergency follow-up visit through our community medicine outreach program.

For emergencies, call 911. This request form is not monitored continuously. Do not wait for a callback if you need emergency help.

Share contact and scheduling details only. Please do not enter symptoms, diagnoses, medication lists, insurance information, medical records, or gate codes. If you are helping someone else, use your own contact details and submit with their permission.

Service area: Home visits are available only at physical addresses inside both Sandoval County and the La Madera Fire District. Enter the visit address below and select Check address before submitting. We verify the address before arranging a visit.

A local EMT will review your request and contact you to discuss the visit, location, and availability. Submitting this form does not book an appointment.

Name *

First

Last

Callback phone number *

Use a number where the local EMT team can reach you.

home Service phone

Email (optional)

Community or neighborhood (optional)

Add a neighborhood name if it helps identify your home. Do not enter gate codes or medical information.

Best time to call (optional)

A general day or time window is helpful. Please do not include health details.

Request acknowledgement *

I agree that La Madera may contact me about a non-emergency follow-up visit. I understand this request does not book a visit and is not monitored for emergencies. If requesting for someone else, I have their permission.

Physical address for the home visit *

Address Line 1

Address Line 2

City

State

Zip Code

Enter the home where the visit would take place, not a PO box. Visits are available only within the La Madera Fire District in Sandoval County, New Mexico.

Service area confirmation *

I confirm that the visit address is in Sandoval County and the La Madera Fire District. I understand that the EMT team must verify the address before arranging a visit.

Address check result *

Use Check address above. This result is filled automatically. The EMT team will confirm service eligibility before arranging a visit.

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