WorkWell Wellness Request - Affiliated Physicians

Request a Worksite Know Your Numbers Clinic

Thank you for your interest in WorkWell NYC's worksite Know Your Numbers clinics.

Please complete the form below and we will contact you to complete the scheduling of your clinic within one week.

First Name *

Last Name *

Email *

Phone *

Agency and Location Information

Note: If you are requesting services at multiple locations, please complete a form for each location

Agency Name *

Name of Location *

Street Address *

City *

State *

Zip *

Total Number of Employees at this Location

Cross Streets *

Parking Instructions * Is there a designated visitor entrance?

Security Present? * If yes, clearance required? What ID will be required of Affiliated Physicians staff?

Building Access * Please provide entrance location

Main Contact Information

Contact Name *

Contact Office Phone *

Contact Cell Phone

Contact Email *

Back-up Contact Information

Contact Name *

Contact Office Phone *

Contact Cell Phone

Contact Email *

Event Information

Event Type

Total Estimated Number of Participants *Note: Use last year's numbers or estimate 30% of on-site employees

Who can attend this event? *

Preferred Event Date

Event Start Time e.g. 8:45 am

Room Selection

Note: Each nurse requires one table, 2 chairs, access to an outlet and a wastebasket (for non-medical wastes). Our nurses will arrive 30 minutes before the event start time to set up.

Event Room Name(s)

Event Room Floor

Other

Will you use our online scheduling site?

Can you send emails to all employees assigned to this location?

Please confirm you can supply a table and chairs for each nurse on the day of your event.

Are there any other details we need to know?