Employee Health

Please complete the information below:

Select the Appointment Type*
How soon do you need your TB Test Results?*
Date Format: MM slash DD slash YYYY
Time*

: HH

MM
Appointment Date*
Appointment Time*
Do you have health insurance?*
File Upload | Front Side | Health Insurance Card
Front Side
File Upload | Back Side | Health Insurance Card
Back Side
Name of Employee
Employee Information*
Please the names of all the employee that will receive TB Testing. Click the + sign at the end of the row.
Employee First Name Employee Last Name Date of Birth (MM/DD/YYYY) Employee Phone Number
State Identification Card
File Upload | Front Side of your State ID/Driver's License*
Front Side
File Upload | Back Side of your State ID/Driver's License*
Back Side
Office | Employer's Address
Employer's Name*
County where Employer is Located:*
Employer Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Service Agreement*
- This form constitutes a Service Agreement between above named Employer and Brij Health to provide tuberculosis screening for students, parents, teachers/faculty and other staff members.
- Brij Health shall maintain the security and privacy of identifiable health information as required by law. Brij Health will comply with all applicable laws and regulations.
- Brij Health will provide qualified, licensed personnel, clinic administrative support staff where required, immunization supplies and consent forms.
- Brij Health require that the Employer guarantees, assures or otherwise commits to a minimum participation.
Signature

Employee First Name	Employee Last Name	Date of Birth (MM/DD/YYYY)	Employee Phone Number

Employee Health

Name of Employee

State Identification Card

Office | Employer's Address