Forms

Name*

Email*

Your phone*

Zip*

Reason for inquiry*

What time of day is best to call? (Monday-Friday)*

Which of our WellMed locations are you inquiring about?*

I understand that I am sending an unencrypted email message to WellMed. I acknowledge and understand that unencrypted email messages are not protected, and that there is a risk of a violation of my privacy, which may include my personally identifiable health information being accessed or viewed by an unintended third party while in transit or when stored on an electronic device, or by hacking or some other means.

I acknowledge that email messages may be inadvertently sent to the wrong email address and may be subject to technical malfunctions. Therefore, I understand that email message delivery is not guaranteed. I understand and acknowledge that WellMed has no responsibility for the content of my email if I happen to misplace my device, if someone views my email messages, or if my device is stolen. I understand that the email messages will be delivered across the networks of various third parties (such as Apple, Verizon, Sprint, etc.), and WellMed makes no representations or warranties regarding the quality, reliability, timeliness or security of such third party networks, or their services or equipment.

Despite the risks, I am authorizing WellMed to communicate with me via email, including by exchanging personally identifiable health information.

I understand that I am responsible for notifying WellMed in writing if I choose to discontinue email communications or if my email address changes.

* - Required Fields

Email

This field is for validation purposes and should be left unchanged.

Find helpful forms you may need as a WellMed patient.

Select how you would like to complete new patient forms: digital or paper.

Paper forms

Your health is important to us

Become a patient

Quick links