Lab Work Specials Registration

Patient: Please complete this section.

Registration Use Only: Please mark all tests required:

The undersigned hereby requests that health screening be performed for me by the organization and individuals participating in the Lab Work Specials under the direction of North Canyon Medical Center. I understand that all screenings will be performed without charge to me whatsoever, expect for the optional blood work.

I hereby release the major sponsors, organizations and individuals participating in the Health Fair from any and all liability including any matter or thing committed or omitted which may arise during blood drawing, vaccination, or other screening or from the data derived there from.

1. The data derived from such screening is to be considered as preliminary only and is in no way conclusive.
2. The responsibility for initiating any follow-up examinations for results outside limits identified at the Health Fair lies with me as the person responsible for my own health and not with any participating organization.
3. Lab Work Specials volunteers will have access to my screening results for the sole purpose of ascertaining the identity of the person tested and determining the correct order for filing/mailing such information.
4. No other individual or agency will have access to my individual screening results without the express written permission from me. Aggregate data may be used to report and research purposes.
5. Insurance cannot and will not be billed for the laboratory services.

Health Fair test results will not be mailed out this year but will be available within 24 hours through the patient portal.