Waitlist

You understand this form is for wait-list purposes only.
You understand that submitting this form does not guarantee acceptance as a patient.
You understand that submitting this form does not create a provider-patient relationship.
You understand this form should not be used for urgent or emergency medical needs.
You confirm that you are age 18 or older, or you understand that T Wellness currently plans to serve adults age 18+ only.
You understand your information will be kept secure and will not be sold or shared for marketing purposes.

Join the T Wellness Wait-list

Full Name*

Date of Birth*

Phone Number*

Email*

Preferred Contact Method (Text, Phone, or Email)*

Are you age 18 or older (Yes or No)*

How do you expect to pay for care? (Insurance, Self-pay, or Not sure)*

Consent & Acknowledgment-1: I agree to be contacted by T Wellness LLC regarding waitlist status and scheduling availability. (Yes/No)*

Consent & Acknowledgment-2: I understand this form does not establish a provider–patient relationship and is not for urgent medical needs. (Yes/No)

Consent & Acknowledgement-3: I understand my information will be kept secure and will not be sold or shared for marketing purposes. (Yes/No)*

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Pahrump, NV, USA

Call Toll Free: (855) 899-8990