District 47 – Wellness Screening Registration Form ***This form works best with Google Chrome*** Company Name: * Crystal Lake School District 47 Screening Location: * Select School Bernotas Middle School Canterbury Elementary School CORE Center Coventry Elementary School Fetzner Operations Center Glacier Ridge Elementary School Hannah Beardsley Middle School Husmann Elementary School Indian Prairie Elementary School Lundahl Middle School North Elementary School South Elementary School West Elementary School Woods Creek Elementary School Bernotas Middle School screening is on the following: Tue 03-23-2021 6:00am - 9:00amTue 04-06-2021 6:00am - 9:00am Canterbury Elementary School screening is on Tue 03-02-2021 6:30am - 9:00am CORE Center screening is on Thu 03-11-2021 6:30am - 9:00am Coventry Elementary School screening is on the following: Thu 03-25-2021 6:30am - 9:00amFri 04-09-2021 6:30am - 9:00am Fetzner Operations Center screening is on Wed 03-17-2021 6:30am - 8:00am Glacier Ridge Elementary School screening is on the following: Wed 03-03-2021 6:30am - 9:00amFri 03-05-2021 6:30am - 9:00am Hannah Beardsley Middle School screening is on the following: Fri 03-26-2021 6:00am - 9:00amWed 04-07-2021 6:00am - 9:00am Husmann Elementary School screening is on Tue 03-16-2021 6:30am - 9:00am Indian Prairie Elementary School screening is on Fri 03-19-2021 6:30am - 9:00am Lundahl Middle School screening is on the following: Tue 03-09-2021 6:00am - 9:00amWed 03-10-2021 6:00am - 9:00am North Elementary School screening is on Wed 03-24-2021 6:30am - 9:00am South Elementary School screening is on Thu 03-18-2021 6:30am - 9:00am West Elementary School screening is on the following: Fri 03-12-2021 6:30am - 9:00amThu 04-08-2021 6:30am - 9:00am Woods Creek Elementary School screening is on Thu 03-04-2021 6:30am - 9:00am Legal Name: * Legal First Name Legal Last Name: * Legal Last Name Status: * Employee Family Member Do you have District 47 insurance? * Yes No - $75 Your insurance status will be validated before the screening. Family member status: * Spouse Dependent (18 and over) Street address: * City: * State: * AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip: * Daytime phone#: * Alternate phone#: Birth date: * Age: Sex: * Male Female Other Email Address: * Tests Requested Please check each additional test below you would like to add to your basic screening Note: Basic screening includes: CMP, CBC, & Lipid Panel Note: Additional lab tests may also be added or changed, the day of your screening Additional tests: PSA (prostate cancer) - $45 Homocysteine (stroke/heart attack) - $65 CA-125 (ovarian cancer) - $50 C-Reactive protein (stroke/heart attack) - $40 Thyroid panel - $45 Osteoporosis testing (urine test) - $58 Arthritic profile - $55 Blood typing - $35 H. Pylori (ulcer/gastritis) - $55 Tetanus/Pertussis - $80 Colon cancer (take home) - $25 Vitamin D levels - $45 Vitamin B-12 - $37 Hepatitis C - $65 All screenings include, height, weight, blood pressure, and body composition analysis Click here for lab test explanations Would you like to pay now or at the screening? * Now At screening Total charges: Total charges: $ Total pre-paid charges: Total pre-paid charges: $ After payment, please click 'Return to Community Health Works' to schedule an appointment 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.