Name *

Please provide the name of the primary contact person for your Awareness Health Screening event.

First Name

Last Name

Organization Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Assessments *

Which tests will be administered during the event? (Not all tests are available in all states.)

Total Cholesterol

HDL Cholesterol

LDL Cholesterol and Triglycerides (8 hour fast required.)

Blood Glucose

Hemoglobin A1c

Blood Pressure

BMI

Abdominal Girth

Body Fat %

Other (please call)

Has a health screening event been held at this location(s) in the past?

Yes

No

Which groups of individuals will have access to the Awareness Health Screening services?

All employees

Spouses and dependents

Limited by health plan membership or other criteria

Expected Participation

How many individuals are expected to participate in your event?

25-50 employees

50-100 employees

100-150 employees

150-200 employees

200-300 employees

300-400 employees

400-600 employees

600-1000 employees

1000+ employees

Start Date

What date would you like to start your Awareness Health Screening (AHS) event?

MM

DD

YYYY

Session 1 Address *

Please provide the name and address for this session.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Session 1 Date *

Please provide the date of this session.

MM

DD

YYYY

Session 1 Start Time *

Please provide the time employees will begin being seen for appointments at this session. (Our staff generally arrives 1 hour prior to this time for set up.)

Hour

Minute

Second

AM PM

Session 1 End Time *

Please provide the last appointment time available for this session. (Our staff generally will leave the location 30 minutes after this time.)

Hour

Minute

Second

AM PM

Session 1 Contact Person *

Who will be on site to allow entry to the location for this session?

First Name

Last Name

Session 1 Phone *

Please provide the cell phone number for this contact person so that we can reach them prior to the session start time.

(###)

###

####

Session 1 Internet Access *

Is there internet access available at this location?

Wireless- Open

Wireless- Password required

Ethernet

None

Session 2 Address

Please provide the name and address for this session.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Session 2 Date

Please provide the date of this session.

MM

DD

YYYY

Session 2 Start Time

Please provide the time employees will begin being seen for appointments at this session.

Hour

Minute

Second

AM PM

Session 2 End Time

Please provide the last appointment time available for this session.

Hour

Minute

Second

AM PM

Session 2 Contact Person

Who will be on site to allow entry to the location for this session?

First Name

Last Name

Session 2 Phone

Please provide the cell phone number of this contact person.

(###)

###

####

Session 2 Internet Access

Is there internet access available at this location?

Wireless- Open

Wireless- Password required

Ethernet

None

Session 3 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Session 3 Date

MM

DD

YYYY

Session 3 Start Time

Hour

Minute

Second

AM PM

Session 3 End Time

Hour

Minute

Second

AM PM

Session 3 Contact Person

First Name

Last Name

Session 3 Phone

(###)

###

####

Session 3 Internet Access

Wireless- Open

Wireless- Password required

Ethernet

None

Session 4 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Session 4 Date

MM

DD

YYYY

Session 4 Start Time

Hour

Minute

Second

AM PM

Session 4 End Time

Hour

Minute

Second

AM PM

Session 4 Contact Person

First Name

Last Name

Session 4 Phone

(###)

###

####

Session 4 Internet Access

Wireless- Open

Wireless- Password required

Ethernet

Non

Session 5 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Session 5 Date

MM

DD

YYYY

Session 5 Start Time

Hour

Minute

Second

AM PM

Session 5 End Time

Hour

Minute

Second

AM PM

Session 5 Contact Person

First Name

Last Name

Session 5 Phone

(###)

###

####

Session 5 Internet Access

Wireless- Open

Wireless- Password required

Ethernet

None

Health Plan Coverage *

Is your organization covered by a MVP Health Care Plan?

Yes

No