Wellness Clinic Request

Company Name:		Contact Name:
Address of Clinic: Postal Code:		E-mail Phone Number:
Clinic Details
Number of Employees Participating in the Seasonal Flu Clinic:
Preferred Month: January February March April May June	July August September October November December	Preferred Day of the Week: Monday Tuesday Wednesday Thursday Friday	Preferred Time: Morning Afternoon Full Day
Special Instructions (Directions, Parking, Security, etc.):
Areas of Interest (Testing)
Blood Glucose Cholesterol Triglycerides Blood Pressure Body Mass Index Cardiovascular Risk Assessment
Areas of Interest (Health Teaching)
Smoking Alcohol Stress Diet and Nutrition	Exercise Diabetes Heart Disease	Men’s and Women’s Health Issues Mental Health Cancer	Respiratory Disease Drug Use Infectious Diseases

Submit your form: