Name *

First Name

Last Name

Date of Birth

MM

DD

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Phone

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Health screenings that will be available

Please check one or all that you may be interested:

Colon Cancer Screening

Hemoglobin A1C (3 month Average Blood Sugar)

Lipid Panel (Total Cholesterol, HDL, LDL, Triglycerides)

Glucose

Anemia

BMI

Height & Weight

Blood Pressure

Eye Exam (Elite Eye Care)