District 34 – Wellness Screening Registration Form ***This form works best with Google Chrome*** Company Name: * Glenview School District 34 Screening Location: * AdminAtteaGlen GroveHenkingHoffmanLyonPleasant RidgeSpringmanWestbrook Admin screening is on 09-15-2021 6:30AM - 10AM 09-22-2021 6:30AM - 10AM 09-29-2021 7:30AM - 1PM Attea screening is on 09-20-2021 from 6AM to 8AM Glen Grove screening is on 09-23-2021 from 6AM to 8AM Henking screening is on 09-24-2021 from 6AM to 8AM Hoffman screening is on 09-28-2021 from 6AM to 8AM Lyon screening is on 09-14-2021 from 6:30AM to 8:30AM Pleasant Ridge screening is on 09-17-2021 from 6AM to 8AM Springman screening is on 09-13-2021 from 6AM to 8AM Westbrook screening is on 09-21-2021 from 6:30AM to 8:30AM Name: * First Last: * Last Do you have HMO or PPO insurance? * HMO PPO Street address: * City: * State: * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip: * Daytime phone#: * Alternate phone#: Birth date: * Age: Sex: * Male Female Other Email Address: * Basic Screening Basic screening includes: CMP, CBC, Lipid Panel, & TSH Flu Vaccination: * No Vaccination Flu Vaccination - Traditional Flu Vaccination - Preservative Free Choose 'Preservative Free' if you have the following conditions: Pregnant, thimerosol allergy... reCAPTCHA Please remember to fast for 8 hours. Black coffee, water, and plain tea are allowed. Once you click submit please wait for the appointment scheduling form to appear... If you are human, leave this field blank.
