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Virgin Pulse Preventive Screenings Form

If you are NOT part of the SSC medical, dental, or vision plan, but would like to earn points for participation in preventative screenings including but not limited to dental cleanings, mammogram, vision exam, colonoscopy, etc., use this form and have your healthcare provider sign off. No results are needed, just the date you completed the screening and your healthcare provider's signature. Points will be credited to your account within 7 days of receipt of the form by Virgin Pulse.

Completed by Participant

Last Name:

First Name:





Date of Birth:






Consent to Use Information. I understand that Virgin Pulse may use personally identifiable information obtained on this Health Care Provider Form, including, but not limited to, my name, date of birth, and screening results (my "Personal Information") to provide health management services to me, which includes using the Personal Information to inform me of relevant health related and health education programs offered by Virgin Pulse or by another service contractor. In the event that Virgin Pulse's services are transitioned to another service provider, Virgin Pulse may deliver my Personal Information to the successor provider to maintain a continuity of services for me.

In addition to any Personal Information disclosed as set forth above, aggregate results, without any identifiable Personal Information, may be made available to the sponsoring entity for program reporting purposes. Virgin Pulse and other contracted data analysis companies may also use my Personal Information as part of group statistical research and analysis. I also understand that my information may be entered into my Health Assessment results by Virgin Pulse. Except for these types of uses and the uses specified in my Virgin Pulse Online privacy policy/terms of use, my Personal Information will not be disclosed by Virgin Pulse.

I certify that the information supplied on this form has been provided to me by my health care provider, and I understand that Virgin Pulse may contact my health care provider listed on this form with questions regarding my information.

Mark the date of completion and obtain the Health Care Provider's signature

Screening Exam Frequency Completed Date HCP Signature
Vision Exam Annually
Dental Exam/Cleaning 2 x Year
Bone density test Annually
Colorectal cancer screening Annually
Breast cancer screening Annually
Cervial cancer screening Annually
Pregnancy glucose test Annually
Prostate cancer screening Annually
Skin cancer screening Annually
Wellness Exam Annually
Complete this form in full. Incomplete or late submissions of this form may delay or eliminate your patient / employee from incentive eligibility. Submit this form using one of the following methods: Fax to 508-302-0055 or Scan and E-mail to

*Allow 7 business days for processing

Questions? Call Virgin Pulse support at 1(888)-671-9395

Please reference your sponsor ID 2812438 when calling.