The offsite biometric screening form is used for those who are unable to attend an onsite screening and/or choose to submit results obtained by a physician.
Completed form is due on or before September 30, 2018 by 11:59 pm CST. Date of test must be on or after October 1, 2017.
Before you submit your form, make sure you have:
- 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
To submit your form, complete the fields below. Click browse to load your document, then click submit.
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.