Physician Form 2012

							          Dear Doctor,

          Your patient is participating in a Wellness Program provided by WellNow LLC. In order to achieve the health
          goals outlined in the program, we require the collection of biometric and lab studies to support maintenance/
          improvement of his/her health.

           Patients will need to have the following biometrics and lab studies:

                   DOCTOR FORM                          PATIENT INFORMATION RELEASE
                                                  I authorize this physician’s office to release
           PARTICIPANT                            my biometric information to WellNow LLC by
           (please print clearly)                 using this form.
           Company Name

           Participant Full Name

           Participant Date of Birth

           Participant Phone #
           Last 4 Digits SS # (required)

           Body Mass Index                        Height: ____________Feet ___________inches               Weight:________lbs
                                                  Waist _____________ inches Hip ______inches              Neck _____inches

           Blood Pressure                         Systolic/                                                Diastolic/

           Blood Glucose & Lipid Values           Blood Glucose:
           Fasting: Yes___ No___                  Total Cholesterol:
                                                  Triglycerides:
                                                  HDL Cholesterol:
                                                  LDL Cholesterol:


Please return this form to WellNow via:

(Mail: 3160 Tremont Avenue, Trevose, PA 19053) (Secure Fax: 215-526-2242) (Email: Scanned Copy to screenings@wellnow.us)

                                   WellNow Customer Service: 866-345-9355
          PATIENT INFORMATION RELEASE

          ______________________                                 ________________________
          Patient printed name                                   Physician Name & Signature


          ______________________                                  _______________________
          Patient signature                                       Date



                 WellNow, LLC 3160 Tremont Avenue Trevose, PA 19053 www.wellnow.us