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If you would like to register by phone call (763) 785-8385
Name
*
First
Last
Phone
*
Email
*
Number of Kids
would you like to REGISTER for a Seminar?
*
Yes
No
Which Seminars would you like to REGISTER for?
*
9:30 a.m. – The Hidden Epidemic: Skin Cancer
10:30 a.m. – What to expect when you’re done expecting: Why you still need your OB/GYN
please check which seminar
would you like to REGISTER for First Aid and CPR Class?
Yes
No
Which time would you like to REGISTER for?
*
10:00 a.m. - First Aid and CPR
10:30 a.m. - First Aid and CPR
11:00 a.m. - First Aid and CPR
11:30 a.m. - First Aid and CPR
12:00 a.m. - First Aid and CPR
please choose which class for First Aid / CPR
Would you like to REGISTER for Ultrasound Screenings?
*
Yes
No
which screening would you like performed?
*
Uterine Fibroid - (10:00 a.m. – 1:00 p.m.)
Varicose Vein - (9:00 a.m. – 1:00 p.m.)
Abdominal Aortic Aneurysm - 9:00 a.m. – 1:00 p.m.
Peripheral Vascular/Arterial Disease - 9:00 a.m. – 1:00 p.m.
Carotid Artery Disease - 9:00 a.m. – 1:00 p.m.
Venous Disease - 9:00 a.m. – 1:00 p.m.
Gallbladder Disease - 9:00 a.m. – 1:00 p.m.
please choose the screening you would like performed
would you like to REGISTER for Women’s Cancer Screening
*
Yes
No
You must Pre-register for a Mammogram and Pap test: 763-783-6196
Would you like to get a Flu shot?
*
Yes
No
Flu shot option: The flu shots cost $23 or it also can be billed to your insurance.
American Red Cross Blood Mobile - Blood Donation?
*
Yes
No
Would you like to Register for the 5K Walk?
*
Yes
No
The 5 K walk will start at noon and will begin and end at the Blaine Medical Center.
Questions you have on Blaine Wellness Day?
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