District 47 – Wellness Screening Registration Form ***This form works best with Google Chrome*** Company Name: * Crystal Lake School District 47 Screening Location: * Home Bernotas Middle School Canterbury Elementary School CORE Center Coventry Elementary School Glacier Ridge Elementary School Hannah Beardsley Middle School Husmann Elementary School Indian Prairie Elementary School Lundahl Middle School North Elementary School South Elementary School Wehde Center West Elementary School Woods Creek Elementary School Bernotas screening is on 03-19-2020 from 6AM to 9AM Canterbury Elementary School screening is on 3-04-2020 from 6:30AM to 9AM CORE Center screening is on 3-10-2020 from 6:30AM to 9AM Coventry Elementary screening is on 3-11-2020 from 6:30AM to 9AM Glacier Ridge & Wedhe Center screening is on 3-16-2020 from 6:30AM to 9AM Hannah Beardsley screening is on 3-02-2020 from 6AM to 9AM Husmann Elementary screening is on 3-06-2020 from 6:30AM to 9AM Indian Prairie Elementary screening is on 3-20-2020 from 6:30AM to 9AM Lundahl screening is on 3-03-2020 from 6:00AM to 9AM North Elementary screening is on 3-17-2020 from 6:30AM to 9AM South Elementary screening is on 3-05-2020 from 6:30AM to 9AM West Elementary screening is on 3-12-2020 from 6:30AM to 9AM Woods Creek Elementary screening is on 3-09-2020 from 6:30AM to 9AM Name: * First Last: * Last 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 Community Health Workswill contact you to schedule an appointment. If you are human, leave this field blank.
