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Worksite Health & Well-Being: Health Screening Request Form

Thank you for your interest in our onsite health screening services. To request a screening, please submit this form and someone from our office will follow-up with you.

Questions? Please email wellnessevents@hfhs.org.

*Asterisk indicates required field.

Today's Date Name of organization Name of requestor Title Name of contact person (if different) Title (if different) Phone Number Email How did you hear about us?

Event information

Desired date of health screening event (the year must be 2022.)

Desired Event Date Desired time of health screening event (indicate start and end times) Expected number of participants Location of event (provide full address)

Health Screening Services

Please note: Participants must be 18+ years old

Check all that apply Blood pressure BMI Cholesterol Blood sugarglucose Health literatureeducation materials Heartstroke risk assessment

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Worksite Health & Well-Being: Health Screening Request Form

Event information

Desired date of health screening event (the year must be 2022.)

Health Screening Services

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Research & Education

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