Completed form is due on or before August 31, 2021 by 11:59 pm CST. Date of test must be on or after September 1, 2020.
- Completed top section of form
- Step 1: Fill out your information AND include email address.
- Step 2: Ensure YOU have signed your form. Without your signature, this form will not be accepted.
- Asked your physician to complete Step 3 in its entirety
The uploader is not available at this time.
You will receive a confirmation email from US Wellness when your form is received and reviewed. If you do not receive an email confirmation within two business days or if you have questions regarding your form, please call US Wellness at (301) 926-6099 x656.