Wellness Screening – Terrible Herbst – SpecialtyHealth Wellness and Prevention Programs

Patient Information and Consent
Name*
First Middle Initial Last
Social Security Number*
Date of Birth*
Month
Day
Year
Gender*
- Male
- Female
Ethnicity*
Health risk may vary depending on ethnicity
Address*
Street Address City State ZIP Code
Phone Number (Must be unique to you.)*
Email Address (Must be unique to you.)*
Biometrics
Height (feet)*
Height (inches)*
Weight (pounds)*
Tobacco use:*
Select a Location:*
Calendar (Click selected date; choose appointment time; then, press submit.)*

September 2026

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September 17, 2026

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3:10 PM

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3:40 PM

3:50 PM
If you select LabCorp option. After you submit your HQ; the LabCorp scheduling link will appear in your email. (Please schedule your appointment for 2+ business days from now.)
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Employer
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ExportDate
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Patient Information and Consent