Documentation Request - TotalWellness

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)

We 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)

How would you like to receive your documentation?(Required)

Fax Number(Required)

Mailing Address(Required)

Street Address Address Line 2 City 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 48 hours to receive the requested documentation. Proof of vaccination documentation and screening results are available 10 business days after the participation date or later. Requests for documentation received within 10 business days of participation may take more than 48 hours to process.

Signature(Required)