Wellness Concepts Event Request

Welcome to the Wellness Concepts health engagement and education services event request portal. Please review the Health Engagement and Education Services Guide prior to submitting your event request(s). To provide the highest level of service, we strongly recommend a minimum of 6 weeks advanced notice to coordinate your events. After successfully submitting your request(s), a Wellness Concepts Client Wellness Manager will contact you within 5 business days to collect any additional details, address questions you may have, and begin planning your event(s).

Planning Contacts

Planning Contact

First Name * Last Name * Company *

Phone Number *

Extension

Email *

Please enter your 9-digit group number

Paid by bank Paid by association

You have {{model.SecondaryPlanningContacts.length}} secondary planning contacts

Payor

Same as the planning contact

First Name Last Name Company

Phone Number

Extension

Contract Recipient

Same as the planning contact Same as the payor contact

First Name Last Name Company

Phone Number

Extension

Event {{$index + 1}}

Event Site Contact

Same as the planning contact

First Name * Last Name *

Phone Number

Extension

Email *

Event Location

Address * Address Line 2 Event Company *

City * State * ZIP *

Event Date

Preferred Date *

Alternate Date

Start Time *

End Time *

Time Zone *

Service of Interest

Service *

Topic of Interest OR Course Name *

Attendance

Projected Participation *

Total Employees on Site

Shipping Info (if applicable)

Same as the event location

Address * Address Line 2

City * State * ZIP *

Wellness Concepts Event Request

Planning Contacts

Planning Contact

{{contact.FirstName}} {{contact.LastName}}

Payor

Contract Recipient

Event {{$index + 1}}

Event Site Contact

Event Location

Event Date

Service of Interest

Attendance

Shipping Info (if applicable)