Acct #                                                                         (CGH use)

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 27 between 8:00am and 11:00am at Grants High School Gymnasium. 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.

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* 1. Please provide the following information

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* 2. How did you hear about these offers? (Select more than one if applicable)

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* 3. Please Choose from the packages below:

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* 4. *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 physician or primary care provider, whether or 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.
Please type in your name below:

We look forward to seeing you at the Annual April Health Fair, Saturday April 27th from 8:00am to 11:00am! If you have any questions/concerns please contact Cynthia Tena (505)287-5208 or Cynthia_Tena@cibolahospital.com

You will also receive an email confirmation with in 24hrs from Cynthia with your registration.

To beat the lines, this year our patient financial services will be contacting you for payment prior to the health fair to make your stop quick and easy!
(Payment is also accepted at the event)

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* 5. Any questions/concerns?

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