WellSolutions Program Work Order

*After you submit a clinic request, a Wellness Company staff member will contact you to confirm the date requested, or offer other open dates. Thank you!*

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 *

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
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

New Program Bundles

Heart Smart Bundle

	I would like to select this bundle:
Components: Blood Pressure Screening, Resting Heart Rate Measurment, and a Stop-by Table for Q&A with a Health Educator.	I would like to select this bundle:

Weigh to Go Bundle

	I would like to select this bundle:
Components: Body Mass Index (BMI) Screening, Body Composition Analysis Screening, and an Ask the Dietitian Stop-by Table.	I would like to select this bundle:

Sun Safety Bundle

	I would like to select this bundle:
Components: DermaView Screening and Stop-by Table with a Health Educator.	I would like to select this bundle:

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