Health Screening Form (U.S. Associates)

Completed form is due on or before November 30, 2020 to be guaranteed updated incentives on your first 2021 paycheck. Date of test must be within the past 12 months of your submission.

Before you submit your form, make sure you have:
  • Completed top section of form
    • Step 1: Fill out your information AND include email address.
    • Step 2: Ensure YOU have signed your form. Without your signature, this form will not be accepted.
  • Ask your physician to complete Step 3 in its entirety

To submit your form, complete the fields below. Click "Select a File" to load your document(s), then "Upload Form" button.


Personal Details
 Date Format: YYYY-MM-DD
Upload Files

For assistance, please contact US Wellness at 855-279-3246.