Wellness Screening Event Registration
Forty Forty Flats, Edina
Thursday, April 11, 2024
45-minute appointments available between 9:30 am and 2:00 PM
Name
First Name
Last Name
Preferred First Name
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Gender Assigned at Birth
Please Select
Female
Male
Not Reported / Not Disclosed
Uncertain / Unknown
Race and Ethnicity (Check all that all)
American Indian / Alaska Native
Asian
Black / African American
Hispanic or Latino Origin
Native Hawaiian or Pacific Islander
White / Caucasian
Other
Do you identify as LGBTQ?
Yes
NO
I prefer not to answer.
Have you ever served in the military?
Yes
No
I prefer not to answer.
Are you a caregiver?
Yes
No
What income category does your household fall into? (Annual Income)
< $13, 590
$13,590 - $18,310
$18,310 - $27,465
$27,465 - $36,620
$36,620 - $45, 775
$47, 775 and above
Insurance Provider (This screening is free and insurance will not be billed.)
Please Select
Aetna
Blue Cross Blue Shield
Bright Health
Cigna
Decline to provide information
HealthPartners
Hennepin Health
Humana
IMCare (Itasca Medica Care)
Medica
Other
PreferredOne
PrimeWest
Sanford Health Plan
Sierra Health
SilverScript
South Country Health Alliance
UCare
Uninsured
UnitedHealthCare
Unknown
Emergency Contact (Name and Phone Number)
Appointment
Submit
Should be Empty: