WTL Health Clinic Pre-Appointment Form

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Please fill out this pre-appointment form. By continuing to the next section, you are confirming that you do not have a current medical emergency.

PLEASE NOTE: If you are experiencing a medical emergency, call 911. If you are in Rhode Island and have questions regarding COVID-19, call the Rhode Island Department of Health's hotline at 401-222-8022 or dial 211 outside of normal business hours.

PATIENT CONTACT INFORMATION

Last Name *

First Name

Sex *

Male

Female

Prefer not to say

Other:

Do you have medical insurance? *

Yes

What allergies do you have? *

Preferred phone number

Email address *

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