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City of <br /> ElkHealthy for Life WIP Program <br /> RiVer <br /> Health Care Provider Certification Form <br /> The City of Elk River has implemented a wellness program designated to encourage employees to make impactful health <br /> choices. A component of the program is encouraging regular exams,such as an annual routine,annual wellness,or annual <br /> preventive exam. <br /> By signing and dating below,you are certifying that: <br /> (patient name)has completed a: <br /> Please check the box to indicate the type of exam: <br /> OMedical Exam O Dental Exam O vision Exam <br /> Health Care Provider Printed Name: <br /> Health Care Provider Signature: Date of Exam: <br /> Phone Number: <br /> Employees shall return this completed form to KKeast@ElkRiverMN.gov <br /> If you have questions,please call Human Resources at(763)635-1023 <br /> Rev.03/18/2019 <br />