Well
Trac
About Us
Services
Patient Check-In
Medical Records
Request An Appointment
Appointment Request
1
Visit Information
2
Personal Information
3
Insurance Information
What is your preferred appointment date
*
*Appointments are available Tuesday through Friday
What time would you like to visit?
Early Morning
Late Morning
Early Afternoon
Have you been to WellTrac before?
*
Yes
No
How did you hear about WellTrac?
Friend
Work
Relative
Health Event
Web
Other
Name
First
Last
Phone
Email
Birth Date
*
MM
DD
YYYY
Address
*
Street Address
Address Line 2
City
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Armed Forces Americas
Armed Forces Europe
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State
ZIP Code
When is the best time to reach you?
Early Morning
Late Morning
Early Afternoon
Preferred Contact Method
*
Phone
E-Mail
Is the insurance in your name/are you the primary insured?
*
Yes
No
Name of Health Insurance Company or Union
Insurance Group Number
Insurance Company Phone Number
Name of employer or union plan
Does your employer reward you for having an annual physical exam?
Yes
No
Questions?
If you need assistance completing this form or would prefer to make your appointment by phone, please call
(702) 266-8180
Schedule An Appointment!
Schedule Your Visit
2500 W. Sahara Avenue, Suite 100
Las Vegas, NV 89102
Phone:
(702) 266-8180 (775) 800-3206
Fax:
(702) 558-8275