Intake form

Name *

Email address *

What type of healthcare resources are you interested in?

Please select at least one option.

Mental Health Services

Primary Care

Dental Care

Specialized Care

Health Insurance Information

Wellness Programs

Fitness Resources

What is your current enrollment status?

What is your preferred method of communication?

Please select at least one option.

Email

Phone

Text Message

In-Person

Do you have any specific health concerns you would like to address?

What is your year of study?

Please specify your major or field of study.

Additional questions or comments

Meducate