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This form is to register for our Health Fair. This year's fair will be held on Saturday, October 14th from 6:30 - 10:00am.
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Please Print clearly and Complete the following information. This form should take 4 or 5 minutes to complete. |
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Patient Full Legal Name
First Name, Middle Initial, Last Name |
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Primary Physician |
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Today's Date |
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Street Address
Full Street Address or P.O. Box |
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City |
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County |
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State |
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Zip Code |
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Telephone
Area Code and 7 Digit Number |
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Email Address |
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Date of Birth |
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Marital Status |
Single Married Divorced |
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Sex |
Male Female |
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Race |
Black White Asian Indian |
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Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number |
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Religion |
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Church Preference |
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Are You Employed? |
Yes No |
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Employer's Name
If you are employed please list your major employer's business name. |
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City |
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State |
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Zip Code
Five Digit Zip Code |
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Employer Phone Number
Area Code Plus 7 Digit Number |
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Occupation |
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Emergency Contact Name |
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Test Selection
Please indicate which test selections you desire |
CMP/Lipid Profile/TSH/CBC $30
PSA (Prostate Specific Antigen $10
Hemoglobin A1c $10
Vitamin D $35
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Treatment Authorization for Cloud County Health Center County Health Fair 2016
I authorize representatives of Cloud County Health Center to draw blood and perform the procedures I have requested on this form. I understand that I have the option of receiving the test results or having them sent to my physician. I acknowledge that no guarantees have been made to me of care, treatment, or provision of medical services.
I understand that I am responsible for full payment for the services provided at this time and that Cloud County Health Center will not bill it to my insurance company.
I certify that I have read and fully understand and agree with its terms and statements. |
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Would you prefer your results to be mailed to self or physician
Please choose one. |
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If you wish for your results to be mailed to your physician, please provide mailing address. |
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