Biometric screening form pdf 2026

1. Click ‘Get Form’ to open the biometric screening form in the editor.
2. In Section 1, fill in your personal information including Date of Birth, Rewards Number, Gender, and Tobacco Use status. Ensure all fields are completed accurately.
3. Proceed to Section 2 and select either Option A or Option B based on how your lab values will be submitted. If you choose Option A, ensure you have your lab slip ready to fax along with the form.
4. In Section 3, enter your Body Measurements and Biometric Results such as Height, Weight, Glucose levels, Blood Pressure readings (Systolic and Diastolic), and Cholesterol levels. Make sure to include the Screening Date.
5. If applicable, complete Section 4 with your Provider’s information including Facility Name, Provider’s Name, Phone Number, and Signature.
6. Finally, in Section 5, check the box for permission to upload your data and sign the form. Review all entries for accuracy before submission.
7. Fax the completed form to Vivacity at the provided numbers and retain a copy for your records.

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