If you'd like to apply to receive Everwell TV for your waiting room, please provide the information below, and we'll get back to you promptly. If you have questions, please contact subs@everwell.com.
Thank you for your interest.
Fields marked with a * are required.
* Contact Name
* Practice Name
Practice Address
City
State
Zip Code
* Phone
Format: (XXX) XXX-XXXX
* Email
* Practice Specialty
Do you currently have video programming in your waiting rooms now?
Yes No
What type of programming?
What kind of Internet access do you currently have?
How many waiting areas do you have at this address?
About how many patients are seen in this office each week?
What percentage of your patients visit more than once a month?
%
On average, how many minutes do your patients spend in the waiting room?
How many additional offices/clinics do you manage?
How many full-time physicians work at this office?
How many part-time physicians work at this office?
How many physicians assistants/nurse practioners at this office?