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I give Cibola General Hospital permission to draw blood samples from me. These samples will be used to perform specific standardized laboratory procedures to determine levels of certain chemicals and substances in my body. |
This test is being performed at my request. I understand that my blood sample will be collected at the Health Fair on April 30th. My results will be mailed to me. |
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Last Name |
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First Name |
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Date of Birth
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Number, Street or PO Box
Complete address is required so your results may be mailed to you. |
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City |
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State |
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Telephone Number |
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Zip Code |
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Physician's Name |
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Physician's Telephone Number |
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Select which screenings you would like performed: (Payment is due at time of service) |
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FREE Cholesterol Screening
A screening tool used to estimate risk for developing heart disease (Fasting is required) |
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$25 Bronze Package ($187 value)
Includes a BMP & CBC
(BMP - 8 Tests used to determine kidney status, electrolyte and acid base/balance and blood glucose.
CBC - To screen for, diagnose, or monitor diseases and conditions that affect blood cells, such as anemia, infection, inflammation, bleeding disorder or cancer.) |
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$49 Copper Basic Package ($253 value)
Includes a CBC, CMP, & Hemoglobin A1C.
(CMP - 14 tests to monitor known conditions, such as hypertension and use of medications to check for kidney/liver side effects.
A1C - Diabetes monitor to aid in treament decisions or to diagnose diabetes) |
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$49 Silver Package for Women ($282 value)
Includes a Lipid Panel and TSH. Fasting Required.
(Lipid Panel - 4 tests to assess cardiovascular disease risk.
TSH - Screens, diagnoses thyroide disorders; to monitor treatment of hypothyroidism/hyperthyroidism) |
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$49 Silver Package for Men ($282 value)
Includes a Lipid Panel and PSA. Fasting required. (Lipid Panel - 4 tests to assess cardiovascular disease risk. PSA - Prostate Cancer Screening.) |
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$99 Gold Package ($707 value)
Includes CBC, CMP, Lipid Panel, Hemoglobin A1C, PSA (men), TSH (women). Fasting required. |
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Please confirm you agree with the statement below by checking the box |
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By Clicking "submit" I understand that these test results are being sent to me for my information only, and that Cibola General Hospital is in no way attempting to propose a diagnosis or recommend medical treatment. I have been informed and I understand that I should give the results of these screenings to my personal physician or primary care provider, whether or not the results indicate any abnormal values. Screenings are available for Cibola County residents age 18 and older ONLY. These results are mailed to you at the address provided at the time of registration. |
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