• D & L Meter Employee Wellness Registration Form

    Formulario de Registro para el Bienestar de los Empleados de D & L Meter

  • Personal Information

    Información personal
  • Date of Birth/Fecha de Nacimiento*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Insurance Information

    Información del seguro médico
  • Do you have medical insurance?/¿Usted tiene seguro médico?*

  • Appointment Information

    Información de su cita

  • Testing hours are 5:45 am - 9:00 am.

    Testing is available during this time window for your convenience.

  • Please indicate which tests should be performed/Indique qué pruebas deben realizarse*

  • Health & Safety Considerations

  • The influenza vaccine should not be taken by certain individuals. 

    If you answer yes by checking any of the following contraindications, the vaccine will not be administered until you have received a physician's approval.

  • Do you have allergies to medications, food, a vaccine component, or latex? Such as: neomycin, eggs, gelatin, MSG?*
  • Contraindication. Please check all that apply*

  • Acknowledgments

    Reconocimientos
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