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Cibola General Hospital

2018 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 28 between 8:00am and 11:00am at Grants High School Cafeteria or by appointment below.My results will be sent to my Primary Care Provider,if I list one below,and the results will be mailed to me and become a part of the legal medical record at Cibola General Hospital. Select which screenings you would like performed: (Payment is due at time of service.)
* Last Name:
* First Name:
* Date of Birth
MM/DD/YYYY
* Mailing Address: (PO Box or Street)
* City
* State
* Zip Code
* Email
* Phone Number
* Provider Name:
* ProviderTelephone #:
* How did you hear about these offers?
(Facebook, Newspaper, Radio, Mail, or Other)
Facebook
Newspaper
Radio
Mail
Other
Please take the time to read the following:
* With assistance from Blue Cross Blue Shield, the first 60people who get labs drawn at the health fair on Saturday, April 28th between 8:00am and11:00am at Grants High School Cafeteria will receive a discounted Hemoglobin A1C with the silver and gold packages. * Cibola General Hospital also will offer these discounted packages outside of thehealth fair hours. You mustsign up online by Friday, April 27that 5pm to receive thisoffer. -Labs can be drawn starting Monday, April 30thuntilFriday, May 11th-Labs will be drawn Monday throughFriday, between 7am and10am -If you should need other options, please call (505)287-5208. -Labs drawn during these times will not receivethe Hemoglobin AIC at a discount.
$25 Bronze Package ($258 value)
Includes a CBC & CMP (CBC - To screen for, and monitor diseases and conditions that affect blood cells, such as $25 due anemia, infection, inflammation, bleeding disorders or other potential abnormalities. CMP - 14 tests to screen and/or monitor certain conditions, such as blood chemistries and kidney, or liver-related problems, among other things.**Fasting Required)
$49 Silver Package ($363 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 certain conditions, such as blood chemistries and kidney, or liver-related problems, among other things. Hemoglobin A1C - To help in the diagnosis of diabetes and monitor status of diabetes for treatment decision.**Fasting Required)
$89 Gold Package ($714 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 SELECT - $89 due or other potential abnormalities. CMP - 14 tests to screen and/or monitor certain conditions, such as blood chemistries and kidney, or liver-related problems, among other things. 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)
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.
* Select Package from the following: Bronze Package
Silver Package
Gold Package
Additional TSH Test
If you are unable to have your labs drawn at the fair:
  • You must sign up online by Friday, April 27th at 5pm to receive this offer.
  • Labs can be drawn starting Monday, April 30th until Friday, May 11th between 7am and 10am
  • Labs drawn during these times will not receive the Hemoglobin AIC at a discount.
  • Reminder, lab packages requires fasting for 12 hours prior to screening, water and prescribed medications permitted
  • Payment is due at the time of service (We accept cash, card or check)
  • SCHEDULING: Please call Cynthia Tena at (505)287-5208 or email Cynthia_Tena@cibolahospital.com to schedule an appointment.
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 am also aware that these labs are an out of pocket cost that will be paid at the time of service; Cibola General Hospital will not be billing any health insurance plans for these tests. If I have not listed a primary care provider to receive a copy of the results, I have been informed and I understand that I should give the results of the screens to my personal primary care provider, whether nor not the results indicate any abnormal values. I understand that the results will be mailed to the address I have indicated and provided to the listed Primary Care Provider (if listed). I am also aware that the test results will also become a part of the legal medical record at Cibola General Hospital. Screenings are available for individuals age 18 and older ONLY.
* Signature
* Date