Journey to Wellness Prescription Pads Request Form

Are you interested in becoming a community partner distributor of the Journey to Wellness Rx? This non-pharmaceutical prescription provides information on obesity and chronic disease prevention and management including physical activity, healthy eating, and tobacco prevention/cessation. The tear-off prescription sheets are designed to be used with the general public at clinics, mobile healthcare units, community screenings, health fairs and other health promotion events. They are available in English, Spanish and Haitian Creole. Complete the request form below to get started!

Your Name *

Your Organization *

Your Email *

Your Phone Number *

Please briefly describe your organization and how the Journey to Wellness Rx Prescription will be utilized. *

Who will you provide the Journey to Wellness Rx to? (please check all that apply)*ClientsCommunity MembersStaff Members

Please select all languages that you are requesting the Journey to Wellness Rx in (please check all that apply).*EnglishEspañolKreyòl

Number of English pads requested (100 prescriptions per pad)

Number of Español pads requested (100 prescriptions per pad)

Number of Kreyòl pads requested (100 prescriptions per pad)

Would you like to pick up the Journey to Wellness Rx materials at the Miami-Dade Department of Health, Office of Community Health and Planning offices located at 18255 Homestead Avenue, Miami, FL 33157? (If so, a representative will call you to confirm a date and time for pick up.)*

Would you like the Journey to Wellness Rx materials delivered to you? (If yes, please provide your address and accommodating details for drop off. Please note it can take up to 2 weeks for delivery time and the delivery address must be within Miami-Dade County. A representative will call you to confirm a delivery time and date).*

Please enter an address if you are choosing to have the materials delivered to you.

Are you interested in having a representative come out and present on the Journey to Wellness Rx Program for your organization?*

DISCLAIMER:
The Florida Department of Health in Miami-Dade County and the Consortium for a Healthier Miami-Dade are NOT endorsing any activity by disseminating this form. The purpose of this form is only to disseminate information about the Journey to Wellness Rx and to coordinate dissemination of Journey to Wellness Rx materials. It is NOT the responsibility of the Consortium to coordinate or determine if there is any sponsorship exclusivity related to any Journey to Wellness Rx related activities. Any questions regarding the Journey to Wellness Rx must be directed solely to the entity utilizing the Journey to Wellness Rx materials.

Please leave this field empty.

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Journey to Wellness Rx Prescription Pads Request Form

Journey to Wellness Prescription Pads Request Form