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 *
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
Contact Name *
Contact Office Phone *
Contact Cell Phone
Contact Email *
Event Type
—Please choose an option—Know Your Numbers Program
Other 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? *
—Please choose an option—All City EmployeesAgency Staff Only
Preferred Event Date
Event Start Time e.g. 8:45 am
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
Will you use our online scheduling site?
—Please choose an option—YesNoUnsure
Can you send emails to all employees assigned to this location?
—Please choose an option—YesNo
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?
