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Contact Us

Address: 1079 South Ancona Avenue, Suite 100, Eagle, ID 83616
Phone: 208-853-2273
Fax: 208-376-3831
Email: CS@PreventativeHealthScreenings.com

Patient Portal Login

Intake Form

Name of Organization*
Contact Name*
First Last
Contact Title/Role*
Contact Phone*
Contact Email*
Organization Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Reason for Contacting Us?
- Schedule an on-site Health Screening and/or Seasonal Flu vaccine clinic at your workplace
- COVID-19 Services: Vaccine, Rapid Antigen Test, PCR Test, Antibody Test
- Schedule a lab draw at our Eagle office
- Other
Number of Employees that you anticipate being interested in participating in a health screening and/or vaccine clinic at your location?
- 10–25
- 25–50
- 51–100
- More than 100

To verify benefits, please complete the following.

Name of Insurance	Subscriber Name	Subscriber Number	Date of Birth

Are there any upcoming dates or time frame that would work well for a health screening/vaccine clinic?
Any other reasons?
Email
This field is for validation purposes and should be left unchanged.

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