Preventive Wellness Visit Form Page 2
ADVERTISEMENT
1
2PREVENTIVE WELLNESS VISIT
DOCTOR FORM
PATIENT INFORMATION RELEASE
PARTICIPANT
I authorize this physician’s office to release my biometric
(please print clearly)
information to WellNow LLC by using this form.
Gordon Food Service
Circle One
Employee
Spouse
Participant’s Full Name
If participant is a spouse,
please print employee’s full
name
Participant Date of Birth
Participant Phone #
Last 4 Digits SS # (required)
GFS Employee ID #
(required)
REQUIRED METRICS
Body Mass Index
Height:______feet ______inches
Weight:________lbs
Blood Pressure
Systolic:
Diastolic:
Current Tobacco User
Yes
No
(circle one)
OPTIONAL METRICS (IF REQUESTED BY DOCTOR)
HbA1c:
Lipid Values
Total Cholesterol:
Triglycerides:
HDL Cholesterol:
LDL Cholesterol:
Fasting (Circle One):
Yes
No
______________________________
__________________________________
Patient Printed Name
Patient Signature
_______________________________
__________________________________
Physician Printed Name & Phone Number
Physician Signature
Return this form to WellNow via the information provided below.
WellNow, LLC 3160 Tremont Avenue Trevose, PA 19053
Email:
screenings@wellnow.us
Secure Fax: (215) 526-2242 Customer Service: (866) 345-9355
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical