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PERSONAL PHYSICIAN WELLNESS AFFIDAVIT FOR USE AT YOUR PERSONAL PHYSICIAN Please use the following form if you prefer to visit your personal physician for your screening. Participant Instructions: • Schedule a visit with your Primary Care Physician. • Complete the Participant Information section of this form • Take this form with you to your appointment and refer them to the instructions below. • Please return form to Greg Austin by February 1st 2024, to qualify for the additional contributions to the employee health coverage. o Fax: [PHONE REDACTED] or email to [EMAIL REDACTED]. • Request blood screening with Lipid Panel and Glucose: o Total Cholesterol, HDL Cholesterol, LDL Cholesterol, Triglycerides and Glucose • Return this form to patient with your signature. • May only bill for Wellness Screening Participant Information Employer: City of Blackfoot Patient Name Patient is Employee (Self) Spouse Wellness Visit Date: DOB: / / mm dd yyyy Please mark the box that the following was checked: Height Weight Waist Circumference Blood Pressure Total Cholesterol HDL Cholesterol Triglycerides LDL Cholesterol Glucose/Blood Sugar Physician Name (please print): Physician Signature Date: Name of Covered