Patient early access

Get your clients priority appointment scheduling

Please read to your client

This form is used to give your information to WellMed or one of its affiliates so they can contact you to schedule an appointment with a WellMed doctor. You understand and agree:

You are giving me your information willingly and you give me approval to give your information to WellMed.
Permission ends after your first visit with your doctor. You may cancel permission before then by telling me, but it won’t cancel information that’s already been shared.

Sharing your email address means you agree to receive an email confirmation. This email will not be encrypted and may contain health information. If you decide not to complete this form, it won’t change how WellMed cares for you.

Please complete the information below.

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Client contact information

Client first name*

Client last name*

Client email*

Phone*

State*

Zip*

Clinic name*

PCP name*

Health plan name*

Health plan effective date*

Broker contact information

Broker name*

Broker email*

Broker phone*

Broker market*

By providing your phone number, you agree to be contacted by WellMed and its affiliates or agents via automated technology such as a text message, an automated telephone dialing system and/or artificial or pre-recorded voice. Communications may include news, events or information regarding new services. You understand Msg & data rates may apply, terms and privacy information are available at https://www.wellmedhealthcare.com/texting-terms/, and text messages will be recurring. If these text messages contain your protected health information, the texts will not be encrypted and others may be able to read the texts. You understand you are not required to provide such consent as a condition of receiving care.

By giving us your email address, you are telling WellMed we may send you messages about health news, events and new and existing services. These emails may have your protected health information in them. They also may be unencrypted.

To opt out at any time, visit https://www.wellmedhealthcare.com/privacy/.

Please acknowledge:*

By clicking this box, you confirm you have read the above to your client.

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Get your clients priority appointment scheduling

Please read to your client

Please complete the information below.

Client contact information

Broker contact information

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