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Cibola General Hospital

2017 Health Fair Screening Registration Form

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 29 from 8:00am to 11:00am at Grants High School Cafeteria. My results will be mailed to me.
* Last Name
* First Name
* Date of Birth
MM/DD/YYYY
* Number, Street or PO Box
* City, State
* Zip Code
* Physician Name
* Physician Telephone #
* How did you hear about these offers?
Select which screenings you would like performed: (Payment is due at time of service) CHECK A BOX
  $25 Bronze Package ($315 value)
Includes a CBC & CMP (CBC - To screen for, and monitor diseases and conditions that affect blood cells, such as anemia, infection, inflammation, bleeding disorders or other potential abnormalities. CMP - 14 tests to screen and/or monitor blood chemistries for certain conditions, such as kidney or liver related problems. **Fasting Required, water and prescribed medications are permitted)
  $49 Silver Package ($415 value)
Includes a CBC, CMP, & Hemoglobin A1C. (CBC - To screen for, and monitor diseases and conditions that affect blood cells, such as anemia, infection, inflammation, bleeding disorders or other potential abnormalities. CMP - 14 tests to screen and/or monitor blood chemistries for certain conditions, such as kidney or liver related problems. Hemoglobin A1C - To help in the diagnosis of diabetes and monitor status of diabetes for treatment decision. **Fasting Required, water and prescribed medications are permitted)
  $89 Gold Package ($662 value)
$89 Gold Package ($662 value) Includes a CBC, CMP, Hemoglobin A1C, Lipid Panel, Vitamin D 25 Hydroxy. (CBC - To screen for, and monitor diseases and conditions that affect blood cells, such as anemia, infection, inflammation, bleeding disorders or other potential abnormalities. CMP - 14 tests to screen and/or monitor blood chemistries for certain conditions, such as kidney or liver related problems. Hemoglobin A1C - To help in the diagnosis of diabetes and monitor status of diabetes for treatment decision. Lipid Panel - 4 tests to help assess cardiovascular disease risk; to monitor and in treatment. Vitamin D 25-Hydroxy - tests measures Vitamin D levels in the blood. **Fasting Required, water and prescribed medications are permitted)
  Add the TSH Test to any package for only an additional $10
TSH - Screens for thyroid disorders; and used to monitor treatment of hypothyroidism/hyperthyroidism.
Please confirm you agree with the statement below by checking the box
* By Checking:
"I agree" 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.