Request a Clinic

Thank you for your interest in bringing a biometric screening clinic to your department!

Please keep the following in mind when requesting your clinic:

We require a minimum of 10 participants. If fewer than 10 participants are scheduled one week prior to the clinic, the clinic may be canceled.
A private conference room, office, or other space is required.
One table and two chairs must be provided for each nurse/clerk at your site. Tables and chair must be stationary (no wheels) and an appropriate size for adults.
Our staff will arrive 30-45 minutes prior to the start of your clinic to set up and will need a contact from your department to meet them. Please keep this in mind when reserving a room and requesting your start time.
We will need 15 minutes to break down at the end of the clinic.
The length of the clinic will be determined based on your location and the number of screenings anticipated, but will not exceed 7 hours 20 minutes.
Clinics are not available on the 2^nd Wednesday of each month.

Please allow up to five business days to process your request.

Questions? Contact URWell_Clinics@URMC.Rochester.edu

Have you scheduled a clinic with us before?:

Yes

Approx. number of eligible* individuals (minimum of 10):*

Department Name:*

Clinic Site Contact Name:*

Email Address:*

Cell Phone Number:

Office Phone Number:*

Back-up Clinic Site Contact Name:

Email:

Cell Phone Number:

Building Name:*

Street Address:*

Suite Number:

Room Name / Number:

City, State and Zip:*

Is there room for a clerk with a separate table at this location?:

Yes

Please provide any details about parking for our staff:*

Handicap Entrance from Parking (if not at URMC campus):*

Location Check-in Details (directions to the location and clinic room):*

Wi-Fi Available:

Yes

Are these clinics open to others in the University?:*

Open

Private

We are excited to bring you our service and your employees will thank you for it too! Due to high demand, we are currently scheduling clinics two months in advance. Please take this into account when requesting dates.

Requested Date(s) and Time(s):

Date:*

Start Time | End Time:*

To request a clinic outside of standard business hours, please include any necessary details in the form below and a member of our team will be in contact with you.

Additional comments or questions:

*For eligibility information, please see our Eligibility and Incentives page.

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