Non-Member Account Information - Family Wellness Fargo

Non-Member Account Information Request

The following form is for Non-Members new to Family Wellness who would like to create an online account for program enrollment. Please allow up to 2 business days for our team to create your account and follow up with access instructions. Please Note: If you've accessed Family Wellness previously as a member or guest, or if this is an urgent request, please call our front desk during business hours at 701.234.2400 prior to submitting this form.

First Name*
Last Name*
Reason for Submission*
Select the correct category from the dropdown so we can forward you submission to the appropriate person for prompt return service!
Date of Birth*
MM slash DD slash YYYY
Email*
Enter Email Confirm Email
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Emergency Contact Full Name*
Emergency Contact Phone*
Additional Family/Household Members
Please use the fields below to add household members to your Non-Member account.
Spouse/Other Adult: Full Name
Spouse/Other Adult: Date of Birth
MM slash DD slash YYYY
Spouse/Other Adult: Email
Enter Email Confirm Email
Dependent/Child 1: Full Name
Dependent/Child 1: Date of Birth
MM slash DD slash YYYY
Dependent/Child 2: Full Name
Dependent/Child 2: Date of Birth
MM slash DD slash YYYY
Dependent/Child 3: Full Name
Dependent/Child 3: Date of Birth
MM slash DD slash YYYY
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Non-Member Account Information Request

Additional Family/Household Members