Event Registration Form

Event Registration Form

Screen For Life-06/14/25

FIRST NAME*

LAST NAME*

DATE OF BIRTH*

MM/DD/YYYY Format

CELL PHONE NUMBER*

TO SEND REPORTS

Phone

PERSONAL EMAIL ADDRESS*

FOR REPORTS TO BE SENT TO

Address Information/City/State/Zip

What insurance do you currently have?*

Private Insurance

Medicare

Medicaid

Employer-Sponsored Insurance

VA/Tricare

Uninsured

Other

Insurance Provider Name/Policy Number

How did you hear about this event?*

SELECT ALL THAT APPLY*

Cancer History Section/ Does cancer run in your family?

YES

true

What type of cancer?

Personal History/ Have you had cancer?*

YES

If yes, What Type Of Cancer?/Current Status?

How often do you go for a wellness check-up?

Once a year

Every six months

Rarely

Never

ARE YOU INTERESTED IN ANY OF THE FOLLOWING COVERED BY INSURANCE?

Men’s Health Services

Annual Wellness Exam

Prostate Screening (PSA Test)

Testosterone Testing & Therapy

Sexual Health & Erectile Dysfunction Treatment

Heart Health & Blood Pressure Check

Diabetes Screening

Mental Health & Stress Management

Weight Management & Nutrition Counseling

Sleep Apnea Evaluation

Excess Skin Removal

Scar Revision

History of Hernia / Groin / Abdominal Pain

History of Scarring

Shoulder Pain

Neck Pain

Numbness / Tingling in Hand or Wrist

Do you suffer from snoring or fatigue?

PREFERRED TIME

Appointments are optional but can help streamline the process for registration.

Select or enter value

MEDICAL TREATMENT CONSENT*

I understand there are risks associated with any medical treatment and that the Medical Provider has explained these risks to me. I acknowledge that no guarantee or assurances have been made to me concerning the results of the treatment.

By checking below, I acknowledge that I have read and agree to the terms of the Medical Consent Form.

COMMUNICATION CONSENT*

I understand and give consent to receive calls, text messages and/or emails from Premier Health Group and all affiliates of the practice. (To receive reports from this event we must receive consent.)

Please Upload

Insurance Card & I.D (Front & Back)

Drag and drop files here or

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