Preventative Health Screening - 2026 Employee Wellness Form

Preventative Health Screening - 2026 Employee Wellness Form

Use the "submit" button when you have completed the form.
Name

First NameLast Name
Email
example@example.com
Department
Total Earned
(read only - will calculate automatically)
Employee Number (not Quick Punch ID)
Your forms must be completed online by October 30, 2026. No late submissions will be accepted. You will receive a one-time payout in December 2026.
Preventative Health Screening: You will receive $50 (examples include mammography, dental, vision, prostate, skin check, colonoscopy, etc).
Screening Date

MonthDayYear
Service or screening you had
Proof of Screening

(upload image of receipt)
Cancelof
PreventativeScreeningDollars
Questions? Contact Kayce Fuhrman at kfuhrman@mhtlc.org or Julie Harrell at jharrell@mhtlc.org
I would like to donate my dollars to Memorial Hospital Foundation. If yes the foundation team will contact you to fill out payroll deduct forms for $50. This will be a one time deduction.
Should be Empty: