Wellness Center Intake Intial Form
Please complete the intake form, you will then be emailed a more specific form for the appointment you choose and scheduling link. Each service has various availabilities so please be aware. Thank you!
Name
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Please indicate your gender
Male
Female
Date of birth
-
Month
-
Day
Year
Date
How did you find out us?
Word of mouth
Website search
Social media
Other media
Other
Which of the following services are you interested in?
*
Routine Vaccine
Travel Vaccine and Consult
Rapid Testing Services for COVID, Flu, Strep, RSV
Treatment Services for UTI, Cold Sore, Motion Sickness, Lice, Acne, Cough
In-depth Pharmacist Consult
ECG - Heart Screening (Who We Play For)
Other
Which Routine Vaccine would you like to receive?
COVID Moderna (only) Booster (**LIMITED AVAILABLITY 2024-CALL MAKE SURE HAVE*)
Flu Shot - High Dose (65+)
Flu Shot - Regular dose
RSV
Pneumonia - Prevnar 20
Pneumonia - Pneumovax 23
Pneumonia - Unknown which need
Shingrix (Shingles)
Hepatitis A
Hepatitis B
Hep A/B Combo
Tetanus/Pertussis (Whooping Cough) -Tdap
MMR
Other
Which Travel Vaccines are you looking to receive?
Hep A
Hep B
Hep A/B Combo
Typhoid
Polio
Rabies
Meningococcal
Other
Which Rapid Test are you requesting?
COVID - Symptomatic ($50)
COVID - Travel ($75)
COVID/Flu Combo ($75)
Flu ($50)
RSV ($50)
Strep ($50)
Other
Which Test and Treat Service are you interested in?
UTI
Motion Sickness
COVID
Flu
Mild Cough
Mild Acne
Cold Sore
Head Lice
Strept
Other
Please describe a little more about the request for the in-depth consult?
Submit
Should be Empty: