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Taylor Regional Hospital

2019 Taylor Regional Hospital Health Fair Registration

2019 Health Fair Consent Form
2019 Taylor Regional Hospital Health Fair
Date: Saturday, June 8th
Time: 7:30 am - 11:00 am
Location: Taylor Co. Intermediate School
Registration runs from April 23 to June 1.
The doctor listed on this form will receive a faxed copy of your lab results. You will receive a copy of your results via U.S. Mail. Please allow two weeks for processing.
* Name:
Full Name
* Address:
* Phone:
* Email:
* Birthdate:
* Sex: Male     Female    
* Primary Doctor First Name:
* Primary Doctor Last Name:
* Address:
* Dr. Phone:
Test(s) Chosen:
* Tests CBC CMP TSH Coronary Risk ($15)
PSA -Male Only($10)
Please pay on the day of the Health Fair; please do not mail payment.
I hereby give my consent to have a sample of my blood drawn for the purpose of laboratory test(s) that I have chosen.
I hereby release Taylor Regional Hospital and any other organization(s) associated with this screening, their affiliates, directors, officers, employees, successors, and assigns, from any and all liability arising from or in any way connected with these tests or the test results. I understand that: 1. The data derived from a test is considered preliminary only and is not considered a diagnosis. 2. The responsibility of initiating a follow-up examination to confirm the results of a test and obtain professional medical assistance is mine alone, and not that of any organization(s) associated with these screenings.
* Participant signature:
* Date: