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WellSolutions Program Work Order
To schedule a Wellness Clinic, please contact Emily Pesaturo (epesaturo@thewellcomp.com) for confirmation of the requested date. Thanks!
Account Information
Client LogIn ID:
*
Submitted Date:
Account Name:
*
Participation List?
*
Yes
No
Contact Person:
*
Phone Number
*
Street Address:
*
City
*
State:
*
Zip Code
*
Contact Email Address:
*
Requested By/Account Mgr:
*
Account Mgr Email Address:
Account Mgr Phone #:
*
Event Information
Event Type
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Wellness Clinic
New Program Bundles
Health Fair
Stand Alone Screening by request
Immunization
Health Education Program
Combination of Events
Circuit Screenings
Online Reg?
*
Yes
No
Vouchers Needed?
*
Yes
No
# of Points
Event Room # or Room Name:
*
Address for Event:
*
Date Event:
*
+
Event Time: Please indicate AM or PM
*
Start:
End:
Time:
Start:
End:
# of Employees:
# of Estimated Participants:
*
Other Languages:
Parking & Entrance Instructions - Please complete this section, don't use TBD:
*
Biometric Screening Services
Choose # of stations/Staff
1
2
3
4
5
Standard Wellness Clinic (FS, BP, REG, HE)
1
2
3
4
5
Blood Pressure
1
2
3
4
5
BMI Only (includes height & weight measurement)
1
2
3
4
5
BMI & Waist Circumference
1
2
3
4
5
Body Comp Analysis
1
2
3
4
5
Bone Density
1
2
3
4
5
Carbon Monoxide (CO)
1
2
3
4
5
Circuit Screenings
1
2
3
4
5
Chair Massage
1
2
3
4
5
Cotinine Screening (fingerstick method)
1
2
3
4
5
DermaView/Sun Safety
1
2
3
4
5
Hand Grip Strength
1
2
3
4
5
Health Educator (results consultations)
1
2
3
4
5
Hemoglobin A1C
1
2
3
4
5
Registration
1
2
3
4
5
TC/HDL/Glu (non-fasting)
1
2
3
4
5
TC/HDL/Glu/Tri/LDL (fasting required)
1
2
3
4
5
Waist to Hip Ratio
1
2
3
4
5
Other Screening: add here
Health Education Programs
Ask the Pharmacist Series
I would like to schedule the following:
Understanding OTCs, Supplements & Questions to Ask About Your Medications
I would like to schedule the following:
Myths & Facts about Generic Medications & Exploring Ways to Save on Pharmacy Expenses
I would like to schedule the following:
"Ask the Pharmacist" Stop-By
I would like to schedule the following:
Health Across the Lifespan
I would like to schedule the following:
Energy for Life
I would like to schedule the following:
Tired of Being Tired?
I would like to schedule the following:
Nutrition
I would like to schedule the following:
"Ask the Dietitian" Stop-By
I would like to schedule the following:
Physical Activity
I would like to schedule the following:
"Ask The Personal Trainer" Stop-By
I would like to schedule the following:
Physical Activity - Exercising the Basics
I would like to schedule the following:
Steppin' Out - 6 week Walking Challenge
I would like to schedule the following:
Preventive Health
I would like to schedule the following:
Sun & Skin Safety
I would like to schedule the following:
Eye Health
I would like to schedule the following:
Bone & Joint Health
I would like to schedule the following:
Heart Health
I would like to schedule the following:
Immune Health
I would like to schedule the following:
Stress Management
I would like to schedule the following:
The Art of Relaxation/Coping With Stress
I would like to schedule the following:
The Effects of Kindness and Gratitude on Your Health
I would like to schedule the following:
Stop the Juggling
I would like to schedule the following:
Smoking Cessation
I would like to schedule the following:
Quit Tips
I would like to schedule the following:
Weight Management
I would like to schedule the following:
Metabolism 101: Weight Management Basics
I would like to schedule the following:
Mindful Eating and Weight Loss
I would like to schedule the following:
Immunizations
Flu Shots
Shingles (Shingrix-2 dose series)
Hepatitis A
Hepatitis B
PPD
MMR
Meningitis
Meningitis B
Tdap
Varicella
Tetanus
Additional screenings/presentations call Emily Pesaturo 401-270-5661