DGI Supply – Wellness Screening Registration Form Company Name: * DGI Name: * First Last: * Last Do you have DGI BC/BS PPO? * Yes No - $65 NOTE: Your insurance status will be validated before the screening... 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 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. If you are human, leave this field blank.