District 47 – Wellness Screening Registration Form ***This form works best with Google Chrome*** Company Name: * Crystal Lake School District 47 Screening Location: * 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 West Elementary School Woods Creek Elementary School Bernotas screening is on: Fri 03-03-2023 from 6AM-8:30AMMon 03-06-2023 from 6AM-8:30AM Canterbury screening is on: Wed 03-01-2023 from 6:30AM-9AM CORE Center screening is on: Wed 03-15-2023 from 7AM-9:30AM Coventry screening is on: Fri 03-10-2023 from 6:30AM-9AM Glacier Ridge screening is on: Wed 03-08-2023 from 6:30AM-9AM Hannah Beardsley screening is on: Thu 03-09-2023 from 6AM-8:30AMThu 03-16-2023 from 6AM-8:30AM Husmann screening is on: Fri 03-24-2023 from 6:30AM-9AM Indian Prairie screening is on: Tue 03-21-2023 from 6:30AM-9AM Lundahl screening is on: Thu 03-02-2023 from 6AM-8:30AMTue 03-07-2023 from 6AM-8:30AM North screening is on: Fri 03-17-2023 from 6:30AM-9AM South screening is on: Mon 03-13-2023 from 6:30AM-9AM West screening is on: Thu 03-23-2023 from 6:30AM-9AM Woodscreek screening is on: Tue 03-14-2023 from 6:30AM-9AM Name: * Legal First Last: * Legal Last Status: * Employee Family Member Do you have District 47 insurance? * Yes No - $85 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 - $47 Osteoporosis testing (urine test) - $58 Arthritic profile - $55 Blood typing - $37 H. Pylori (ulcer/gastritis) - $55 Tetanus/Pertussis - $80 Colon cancer (take home) - $25 Vitamin D levels - $45 Vitamin B-12 - $40 Hepatitis C - $65 Covid Antibody - $89 Iron - $25 All screenings include, height, weight, blood pressure, and body composition analysis Click here for lab test explanations Do you have any of the following? Diabetes High Blood Pressure Thyroid Disease Heart Disease Lung Disease Are you taking any medications related to the above? 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.
