Forms

Preventative Care Form 2020-2021
Use this form for preventative visits, such as: dental cleaning, eye exam, mammogram, flu shot, skin cancer screening, annual gynecological exam, colonoscopy, heart screening, etc.


Physician Wellness Screening Form 2020-2021
Biometric screenings are conveniently offered on the UCA campus. Onsite screenings are the most convenient option for employees and do not require use of this form because screening results are sent directly to HealthCheck360. If you prefer to have your primary care provider perform your biometric screening, please print and present this form to your doctor. Return the completed form to HealthCheck360. Email: support@healthcheck360.com or fax: (563) 587-5720.