Valeo Biometric Screening for Team Members

Valeo Wellness Screening for Team Members

2026 Health Screening for Valeo Team Members and their spouses.
Name*

First NameMiddle NameLast Name
Additional last name (if needed)
Second last name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
MaleFemale
If you would like a morning appointment, choose here:
If you would like an afternoon/evening appointment, choose here:
Email*
example@example.com
YESNO
Physician's Name
In what city is your physician's office located?
YESNO
I desire to participate in the Valeo health and wellness program and willingly give my consent for evaluation of my present level of health and fitness. I understand that Schneck is providing the biometric screenings, but is not responsible for the provision of care. Therefore, I accept the responsibility of taking any appropriate actions indicated as a result of health problems or high-risk indicators identified during testing. I understand the risks involved in testing, and assume personal responsibility for my health and safety while participating in this program. I further release Schneck Medical Center, its officers, directors, employees, and screening personnel from any and all liability that may occur as a result of my participation. If indicated "YES" above, I give Schneck permission to send my results to my primary care physician for further care and treatment if necessary.

I understand that in signing my name below, I have given my consent and release as described above.
Electronic Signature I understand that my electronic signature is the equivalent of my handwritten signature and I am legally bound to this agreement.*

Powered by Jotform SignClear
Please verify that you are human*
Should be Empty:

Valeo Wellness Screening for Team Members