subject_line
WellSolutions Program Work Order
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
*
Wellness Clinic
Health Fair
Stand Alone Screening
Bone Density
InBody
Combination of Events
Chair Massage
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
Body Comp Analysis (Hand Held Device)
1
2
3
4
5
InBody
1
2
3
4
5
Bone Density
1
2
3
4
5
Carbon Monoxide (CO)
1
2
3
4
5
Chair Massage
1
2
3
4
5
Cotinine Screening
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
Other Screening: add here
Immunizations
For all immunization requests, please contact Kim Balasco at 401-270-4480. Thanks!
Additional screenings/presentations call Emily Pesaturo 401-270-5661