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Cloud County Health Center

Health Fair Pre-registration

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.
Please Print clearly and Complete the following information. This form should take 4 or 5 minutes to complete.
* Patient Full Legal Name
First Name, Middle Initial, Last Name
* Primary Physician
* Today's Date
* Street Address
Full Street Address or P.O. Box
* City
* County
* State
* Zip Code
* Telephone
Area Code and 7 Digit Number
* Email Address
* Date of Birth
* Marital Status Single     Married     Divorced    
* Sex Male     Female    
* Race Black     White     Asian     Indian    
* Social Security Number
Nine Digit Social Security Number
* Religion
* Church Preference
* Are You Employed? Yes     No    
* Employer's Name
If you are employed please list your major employer's business name.
* City
* State
* Zip Code
Five Digit Zip Code
* Employer Phone Number
Area Code Plus 7 Digit Number
* Occupation
* Emergency Contact Name
  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
* 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.
  Would you prefer your results to be mailed to self or physician
Please choose one.
  If you wish for your results to be mailed to your physician, please provide mailing address.