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Ellsworth County Medical Center


Consent to Participate
I acknowledge and agree that I am voluntarily participating in Ellsworth County Medical Center's health fair screening. My involvement is as a participant and not as a patient. I further acknowledge and understand that the screening is limited in nature and is not a substitute for seeking medical treatment or follow up with a health care provider.
Types of Screening
I acknowledge and understand that the health fair is offering the following screenings: Health Fair Profile, Prostatic Specific Antigen, Thyroid Profile, Hemoglobin A1C.
Consent for Blood/Body Fluid Testing Risks
I acknowledge and understand that by participating in the health screening I will be required to submit to blood and/or body fluid testing. I understand that I may experience slight pain or a bruise at the puncture site. There is also the risk of an accidental needle puncture or other biohazard exposure. In such a case, I authorize additional precautionary testing of the sample.
Preliminary Results
I further acknowledge and understand that the screening results provided to me at the health fair are preliminary in nature and are in no way conclusive. I further understand that the screening is not diagnostic and it could fail to detect certain abnormalities that might be detected by more definitive screenings; or it might detect apparent abnormalities that would be found normal with more conclusive testing. For a conclusive medical diagnosis of any medical condition I may have, I understand that I need to be examined by my personal health care provider.
I understand that the Medical Center will maintain the confidentiality of the screening results in accordance with their Notice of Privacy Practices for Laboratory Health Fairs and applicable state and federal laws. By signing this form, I acknowledge that I've been given the opportunity to review the Notice.
Waiver and Release of Liability
In exchange for being given reduced cost health screenings, I release, discharge, and hold harmless, Ellsworth County Medical Center, its employees, agents, officers, members, and health fair participating health care providers from any and all claims, demands, losses, damages, or injuries, arising from, or based in whole or in part on, my participation in the Hospital's health fair, including, but not limited to, the results of the health fair screenings; any statements made to me by any health fair agent, employee, or volunteer; nondisclosure to me of any information; or my receipt or non-receipt of any information from the health fair.
1 have read this form, or have had it read to me, and understand the contents. I believe that I have the knowledge upon which to base consent to participate in the Medical Center's health fair. All questions have been answered to my satisfaction. I hereby give consent to the screenings indicated below.
* Health Fair Participant ACKNOWLEDGMENT:
Full Name
* Date
* Address
* Gender Male     Female    
* Date of Birth
* Phone Number
* Doctor
* Select the Test(s) Health Fair Profile - $30 HFF
PSA (male prostate screening) - $30 HFP
Thyroid Profile - $20 HFT
HgbAIC (diabetes screening) - $25 HFA
* Total $
ECMC will only share results with your physician if there are critical values and with your consent. Please see below:
  Health Care Provider Name
Consent to Share Results. I understand that I can choose to have the screening results sent to my personal health care provider by providing my health care provider's name below:
* I agree that my consent to share the screening results does not relieve me of my responsibility to contact my personal health care provider to confirm that he/she received the results and to request further recommendations related to the results (office visit, additional testing, medication change, etc.).
Patient Initials