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• Physician’s may complete the physician’s results form between 4/1/2025 and 3/31/2026.• Employees are responsible for turning in this physician form, it is NOT the responsibility of your health care provider.This section should be completed by patient before providing the form to the health care provider:Please provide the following information relating to completing my annual physical. By signing this Form, I authorize you to provide this data to Pogue Construction.Patient Name:____________________________________ Date of Birth:_______________________Patient Address: ____________________________________________________________________Patient Phone Number: ______________________________________________________________ Check box to indicate if you are the covered employee, spouse, or dependent of a covered employee: ප Employee ප Spouse ප Dependent (18+)If spouse, please provide employee name: _______________________________________________Patient Signature: ________________________________ Date:______________________________Dear Doctor/Health Care Provider: My employer is sponsoring a wellness program to help make positive changes or to maintain my good health. I have voluntarily enrolled in this program. The health management program offered through Pogue Construction is not intended to treat, diagnose or replace physician involvement, but rather to create and promote an atmosphere of healthy living and learning through the implementation of wellness initiatives. Pleaseperform the following preventive tests and measurements: Full cholesterol panel, glucose (or A1c) and triglycerides Blood pressure Height, weight and waist circumference Other preventive tests may be completed as deemed appropriate for the member.To be completed by the Physician/Health Care Provider:I certify that (Patient Name): _____________________________________ has had their annual physical. Physician/Health Care Provider (Print Name): _________________________ Date: __________________ _Physician/Health Care Provider License Number: ________________________________________________Physician/Health Care Provider Phone Number: ___________________________________________ _____ Physician Health Care Provider (Signature): _________________________________________________ __ Address: ____________________________________________________________________________ ___Thank you in advance for your cooperation and if you have any questions, please feel free to call Pogue Construction – Benefits and Payroll Department at (972) 529-9401 for assistance.by 3/31/2026