Wyoming Wellness Center

FOR ESTABLISHED PATIENTS ONLY

Please fill out this form completely. We want to get you Scheduled 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!

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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, if you haven't set up your UPDOX PORTAL account, created a password and a 5-digit pin, please do so.

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Patient Information

Have you been seen at WWC within the LAST YEAR? *

First N.ame (Copy)

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

Basic Medical History

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

What Services are You Wanting an Appointment for at Wyoming Wellness Center?

Please Select Your Appointment Reason * Describe Treatment / Appointment Requested if "Something Else" was Selected Above What Location do you want to be seen at? *

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How Soon Do You Want to Be Seen? *

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What Days of the Week are you Most Available? (Check all that apply) *

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What Times of Day are you Available? (Choose all that Apply) *