Fasting Lab Employee Wellness 2026 Screening Form

Fasting Lab Employee Wellness 2026 Screening Form

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

First NameLast Name
Email Address
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.
Fasting Lab Screening (Lipid, AIC and Vitamin D Screening): You will receive $50 (You must get all labs drawn to be eligible) (Rural locations can draw at individual sites). LIMIT ONE FREE DRAW PER YEAR.
Fasting Lab Screening Date

MonthDayYear
Upload document here

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Fasting Lab Dollars
I would like to donate my dollars to Memorial Hospital Foundation. If yes the foundation will contact you to fill out payroll deduct forms for $50. This will be a one time deduction.
Should be Empty: