Baird Preventative Submission

Baird Non-Baird Dental or Vision Preventative Exam Form

Non-Baird Dental or Vision Preventive Exam Form Secure Submission

Submit your completed Non-Baird Dental or Vision Preventive Exam Form by 5 PM CT on September 19, 2025.

Your form will be added to your B\Well account within 10 business days. If additional information is needed, you will be notified by email. If your form is approved, you will be notified by email.

Before you submit your form, please complete the following steps:
- Print clearly and review your form to ensure it is complete
- Confirm the date of screening is within the program date range: 9/21/2024 - 9/19/2025
- Provide a valid email address so we can contact you regarding the status of your form
- Ensure you and your doctor have signed your form – Bothsignatures are required
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