Vaccination or Screening Documentation Request Form Please complete the form below to request a copy of your service documentation.Have you already received the service you are requesting documentation for?(Required)YesNo, I will receive the service in the futureWe recommend using your phone to take a picture of your completed consent form at the time of service. We only allow documentation requests for services that have already been provided. Please return to this form after services have been provided if you prefer not to take a picture of your consent form.Participant Name(Required) First Last Date of Birth(Required) Email(Required) Company Name(Required)Location where service was provided:(Required) City State / Province / Region Date of Event(Required) Please select the type of documentation you are requesting.(Required)Proof of Flu VaccinationProof of Covid VaccinationProof of Flu & Covid VaccinationsScreening Results obtained via Onsite EventScreening Results obtained via Lab VoucherScreening Results obtained via Home KitHow would you like to receive your documentation?(Required)EmailFaxMailFax Number(Required)Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code By completing and signing this form, I give TotalWellness permission to release to me a copy of my flu shot consent form as proof of vaccination or my screening results according to the method identified above. I understand that if I select fax or email, the information will be sent via an unencrypted email or unencrypted fax line. I understand that it may take up to 10 business days to receive the requested documentation.Signature(Required)
