P H YS I C I A N R E S U LTS F O R M
Instructions for completion
Participant Instructions
Schedule an appointment with your healthcare provider.
Make sure that all of your personal information on this form is correct.
You will need to fast for 8 hours before your sample is collected at your appointment (water is allowed). Please discuss
this with your healthcare provider.
Prior to your appointment, verify your healthcare provider is able to measure all required fields as noted on the form.
Bring the form with you to your appointment for your provider to complete. All required fields (denoted by asterisk)
must be completed in order for your form to be processed.
Fax the completed form (or have your provider fax it) to the number provided on the form. Alternatively upload your
results through the LetsGetChecked portal. It is your responsibility to ensure the form is completed and submitted
correctly.
Go to the LetsGetChecked portal to upload your form. On the overview tab, there will be a link to upload your form.
Follow the on-screen instructions to upload an image of your form.
You will receive an email once the form has been received and successfully processed.
If you have already completed your annual preventive care visit, your healthcare provider's office may charge a co-
pay and/or a form completion fee. You are responsible for paying co-pays and/or fees.
Provider Instructions
Complete the “Provider Information” and “Health Measurements” sections of the form. Please sign, date and enter your
practice information.
Ensure the values are provided for all required fields (denoted by asterisk) to ensure form can be completed correctly.
Please note that fasting (8 hours) prior to sample collection is required. It is important that you inform your patient of
this prior to their appointment.
Once you have recorded your patient's results and completed this form, please fax it using the number provided on the
form. Alternatively, you should arrange for your patient to pick up the completed form so they can upload the results to
their LetsGetChecked portal.
P H YS I C I A N R E S U LTS F O R M
53f77d22-f87d-4533-811e-209680da65b5
To qualify for your incentive, you must schedule and complete your annual physical exam with your health care provider, and submit
your completed physician's result form to LetsGetChecked by digital upload or fax (305) 489-8502 within your current plan year.
By submitting this form I am requesting my physician to report biometrics results to LetsGetChecked to be included as
part of a sponsored wellness program.
Tanner Ayers Sex: Male
20448 Fire Stone Date of birth: 11/14/1995
San Antonio, Texas, 78264 LGC ID: 92be868b-0bc2-405a-b61a-c16503649302
Health Measurements * Mandatory fields
Date of exam or lab test * Fasting *
MM DD YYYY hrs
Blood Pressure Height Weight Waist Hip
/ . . . .
Systolic Diastolic Ft Inches Pounds Inches Inches
Total Chol HDL LDL Triglycerides Glucose A1C
.
mg/dL mg/dL mg/dL mg/dL mg/dL %
Provider Information * Mandatory fields
By signing below, I attest to the accuracy of the screening data contained in this form.
Health Provider's Signature * Date (MM/DD/YYYY) * Office Street Address
Provider Name (Please Print) * NPI Number Office City, State & Zip Code
Email Address Office Phone Number
These results will be reported to LetsGetChecked. LetsGetChecked or its partner laboratories did not perform this test and
are not responsible for any errors or inaccuracies. Please fax all completed forms to (305) 489-8502.
