Employee Health

1. Appointment Type

Select the Appointment Type*

Which date would you to schedule an appointment?*

Time*

Appointment Time*

How soon do you need your TB Test Results?*

What time is best to contact you or your Employer with the results?*

Do you have health insurance?*

File Upload | Front Side | Health Insurance Card

Front Side

File Upload | Back Side | Health Insurance Card

Back Side

Will your Employer pay for your appointment at Brij Health?*

Employee Information*

Please the names of any or 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

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

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.

Employee Signature