Ormat – Wellness Screening – SpecialtyHealth Wellness and Prevention Programs

Patient Information and Consent
Name*
First Middle Initial Last
Date of Birth*
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)*
Appointments
Select a Location:*
For accuracy of the lab results, you need to fast for 10 hours prior to your lab draw, but drink plenty of water. Black coffee is ok.
Calendar (Click selected date; choose appointment time; then, press submit.)*

November 2024

Sun Mon Tue Wed Thu Fri Sat

1 2
3 4 5 6 7 8 9
10 11 12 13 14 15 16
17 18 19 20 21 22 23
24 25 26 27 28 29 30
If you select LabCorp option. After you submit your HQ, you will be redirected to a LabCorp website to schedule your appointment. (Please schedule your appointment for 2+ business days from now.)
Hidden
For administrative use only:
Hidden
Employer
Hidden
ExportStatus
Hidden
ExportDate
MM slash DD slash YYYY

Patient Information and Consent