Inova Screening Details

Inova Health offers a wide variety of health screenings for area residents. The Inova Health Screening Form is a convenient way to find out which screenings are available and schedule an appointment. The form can be filled out online or printed and brought into one of the participating Inova locations. Appointments are available on a walk-in basis, but appointments are strongly recommended to ensure that you receive the screening of your choice. Screenings vary in cost, but all screenings offered by Inova Health are affordable. Most insurance plans accepted by Inova Health will cover the cost of these screenings. In addition to health screenings, Inova also offers laboratory services and physical exams.

Here is the details concerning the file you were looking for to fill in. It will tell you the time it will take to fill out inova health screening, exactly what fields you will need to fill in, and so on.

QuestionAnswer
Form NameInova Health Screening
Form Length1 pages
Fillable?Yes
Fillable fields80
Avg. time to fill out16 min 19 sec
Other namesinova biometric screening, wellaware inova, inova endocrinology doctors, inova well aware health screening

Form Preview Example

 

 

 

 

 

 

 

«Please select one

 

 

 

 

 

 

Employee Spouse or Domestic Partner

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT ID

«

 

ID

 

«

HISTORY

 

EMPLOYEE

 

 

 

 

 

 

 

 

Did you participate in the Inova Health

 

 

 

 

 

Screening in 2014? Yes No

 

PATIENT INFORMATION

 

«Last Name:

 

First:

 

 

 

Middle Iniial:

«Address (Home or Mailing):

 

«City:

 

 

«State:

 

«Zip Code:

 

«Primary Phone:

 

«Date of Birth:

 

 

«Age:

(

)

-

/

/

 

 

 

«Secondary Phone:

 

«Sex:

 

 

 

(

)

-

M

 

F

 

 

 

«Email:

 

 

«Employer Name:

 

 

 

 

 

YOUR PHYSICIAN

INFORMATION

«Physician’s Name:

 

«Pracice Name:

«Pracice Phone Number:

PATIENT CONSENT

I consent to submit my sample to Health Diagnostic Laboratory, Inc (“HDL”) for testing. HDL works with physicians who will order your laboratory test(s) when medically appropriate. These physicians will not diagnose or treat you. The blood testing service from HDL (a) is provided solely for informational purposes and does not constitute treatment or diagnosis of any medical condition or the practice of medicine; and (b) is not being used as a substitute for the care, medical advice, or treatment provided by your primary care physician. You are solely responsible for forwarding your test results to your primary care physician and following up with that individual. HDL and HDL physicians shall not be liable for your failure to consult with your primary care physician or another medical professional following receipt of test results. When you participate in a blood test from HDL, you are doing so with the understanding that you/your employer is privately paying for these tests and there will be absolutely no billing to Medicare, Medicaid, or private insurance. I have read the above terms and conditions and agree to them.

 

 

 

 

 

/

/

 

 

 

 

 

Patient Signature

Date

 

 

 

 

 

 

 

 

 

NOTICE OF PRIVACY PRACTICES

 

 

I acknowledge that I have reviewed HDL Notice of Privacy Practices and understand that it may be revised from time to time. I understand that any changes will be posted on HDL’s website, www.hdlabinc.com, and that I am entitled to receive a copy of the notice upon request.

«

/

/

Patient Signature

Date

 

Office Use Only:

We attempted, but could not obtain written acknowledgment of receipt of our Notice of Privacy Practices, because:

Patient refused to sign

Emergency Situation

Other:__________________________________________________________________________________

PHLEBOTOMIST USE ONLY

 

Has the Paricipant previously had their

 

YES

 

 

NO

 

 

If yes, where?

 

 

 

 

 

 

 

 

labs drawn by HDL?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the Paricipant

YES

 

NO

 

 

Does the Paricipant have a

YES

 

NO

 

 

 

 

pregnant?

 

 

 

 

 

pacemaker?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Biometrics

 

 

 

 

 

Drawing Lab:

 

 

 

 

 

 

 

 

 

 

 

 

Height:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

feet

 

 

 

inches

 

 

Tel. No.:

)

 

 

 

-

 

 

 

 

 

 

 

Weight:

 

 

 

 

 

 

 

 

 

 

(

 

 

 

 

 

 

ext:

 

 

 

 

 

 

 

 

pounds

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Collecion Date & Time:

 

 

 

 

 

 

 

 

 

 

Blood

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:

 

 

 

 

 

 

Pressure

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

am/pm

(mm/Hg):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Systolic

 

 

 

Diastolic

 

 

 

Phlebotomist

 

 

 

 

 

 

 

 

 

 

 

 

Waist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Circumference

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(inches):

 

 

 

 

 

inches

 

 

Fasing:

 

Yes

 

 

 

 

 

 

No

Body Composiion (%):

 

 

 

 

 

 

 

 

 

 

 

Hrs

 

 

 

 

 

 

 

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Internal Use Only: All fields with a «are complete.

Location is checked.

Phlebotomist Use Only is complete.

Initial:_______ Date:________

*INSTRUCTIONS:

This form MUST be typed, signed, printed and brought to your health assessment appointment. Handwritten copies will NOT be accepted.

REQUESTING LAB/INSTITUTION

Inova WellAware Health Screening

V1.3

 

HDL Overseeing Physician: Thomas D. Dayspring, MD

 

«Please select your location of employment, or "spouse" if applicable

Inova Fairfax Medical Campus - 0010898

Inova Alexandria Hospital - 0010899

Inova Fair Oaks Hosptial - 0010900

Inova Loudon Hosptial - 0010901

Inova Mount Vernon Hospital - 0010902

Inova Medical Group - 0010903

Inova Continuum of Care - 0010905

Inova Healthplex-Urgent Care Centers - 0010906

Inova System Office - 0010904

Inova Spouse-Domestic Partner - 0010907

CUSTOM PANELS

Custom Employer Panel

Lipid Panel hsCRP Insulin Glucose HbA1c

TSH

ALT Creatinine Cystatin C LDL-P & HDL-P

Joseph P. McConnell, Laboratory Director 737 N. 5th Street, Suite 103

Richmond, VA 23219

CLIA No. 49D1100708 | CAP No. 7224971 | NPI No.

1629209853

How to Edit Inova Health Screening

It shouldn’t be difficult to fill out wellaware inova using our PDF editor. Here's how you can rapidly prepare your file.

Step 1: Click the "Get Form Now" button to begin the process.

Step 2: Now you can edit the wellaware inova. You should use the multifunctional toolbar to add, delete, and alter the content material of the file.

Prepare the wellaware inova PDF and type in the details for every part:

step 1 to completing  inova wellaware health screening

Step 3: Select the Done button to make certain that your finished document may be exported to any kind of device you want or mailed to an email you specify.

Step 4: It is more convenient to prepare duplicates of the form. There is no doubt that we will not distribute or see your data.

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .