Wyoming Wellness Center

Please fill out this form completely. We want to start your care at Wyoming Wellness Center (WWC) as quickly as possible. If you have any questions, please contact the office at 307-532-3035.Thank you! We are looking forward to caring for you!

We will be reaching out to you via UPDOX. This is a HIPAA compliant messaging system we use at WWC to communicate with our clients. You will receive a text message as well an an email from UPDOX, on behalf of WWC, asking you to sign into your UPDOX PORTAL account, create a password, and also a 5-digit pin.

Patient Information

First Name * Last Name * Date of Birth * Sex * Cell Phone * Email Address *

Basic Medical History

Allergies to Any Medications? * What is Your Height? * What is your Weight? *

What Services are You Interested In from Wyoming Wellness Center?

Please Select ALL Services You are Interested in at WWC: * Describe Treatment Requested if "Something Else" was Selected Above Did You See and Understand: The Price of Therapies for Treatment at WWC? * Do You Understand: We DO NOT Accept Insurance? * Do You Understand: We Will Provide You Super Bills (if you request) that You Can Submit to Your Insurance Company. They Might Reimburse You for Part of the Costs of Your Treatments at WWC? * Did Someone Refer You to WWC or How Did You Hear about Us? *