Health Educator Appointment Request Form

A Health Educator will reach out within 72 hours to schedule an appointment based on your responses below.

This is for Health Education only. If you are thinking of self-harm, please call 988. If you have specific health needs, please reach out to your primary care provider.

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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Phone Number

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* 5. Preferred Appointment Day

Monday

Tuesday

Wednesday

Thursday

Friday

No Preference

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* 6. Preferred appointment time

Morning (9 AM EST | 6 AM PST through 11 AM EST | 8 AM PST)

Afternoon (11 AM EST | 8 AM PST through 3 PM EST | 12 PM PST)

Evening (3 PM EST | 12 PM PST through 6 PM EST | 3 PM PST)

No Preference

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* 7. Reason for appointment

Health Condition Information (Learn more about condition and/or how to manage it)

Health Education (reinforce healthy habits, exercise, nutrition, screening information, etc.)

Support (create goals/motivation for achieving health goals)

Caregiver support/resources

Technology Support (learn how to use your smartphone, use the internet, etc.)

Community Resources (find local places that can assist with food, housing or transportation)

Access online health resources and tools (connect with your doctor online, HumanaNeighborhoodCenter.com, MyHumana, Go365, etc.)

Other (please specify)

Health Educator Appointment Request Form

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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Phone Number

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* 5. Preferred Appointment Day

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* 6. Preferred appointment time

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* 7. Reason for appointment

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* 8. What state do you reside in?