Fall Health Fair Sign Up Form

Fall Health Fair Sign Up Form
NEW LOCATION for Fall Wellness Lab Draws!

Please report to CRHC’s Rehabilitation & Sports Medicine Center

Located just east of the hospital

220 Essie Davison Dr, Clarinda, IA 51632
Please choose one of the following*

I am an individual signing up for wellness lab draws for myself and NOT through an employer.I am an individual signing up for wellness lab draws through my employer to be held at my workspace.
If applicable, please enter your workspace
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Number*

Area CodePhone Number
Evening Number

Area CodePhone Number
Email
example@example.com
If you haven’t yet joined our VIP Health Fair Email list and you want to be notified of future health fair dates, please check this box and provide us your email address.
Gender*

MaleFemale
Age*
DOB*

MonthDayYear
Date
Please select your preferred Lab Draw date:*
Choose all that apply. Payment will be taken at time of service.
Please check all the lab tests you would like performed:*

Wellness Screening (22 blood tests) - $35Prostate Screen (PSA - men only) - $20Hemoglobin A1C (Diabetic) - $15Vitamin D 25 OH (Vitamin D deficiency) - $30MedGem - (Patient will schedule/pay separately) - $30DXA Body Composition Scan (Patient will schedule/pay separately) - $30US Abdominal Aorta Screening (Patient will schedule/pay separately) - $60
Amount Due in $:
This is the amount due at time of service.
ATTENTION: You have selected DXA Body Composition Scan. Please note that appointments may not be available on the same day as your scheduled health fair lab draws. The DXA Body Composition scan is not a bone density scan. To learn more about the DXA Body Composition scan check out our Radiology Services page.
ATTENTION: The MedGem® is a handheld indirect calorimeter that determines an individual’s resting metabolic rate (RMR*). This diagnostic test is completed by our Dietitian and upon completion of the analysis you will be provided a personalized report regarding metabolism, energy expenditure, and nutrient/caloric needs. Learn more about this tool on our Dietitian Services page.
Lab draws are being offered at the following locations.
During your lab draw would you like to also receive an influenza immunization?*

YesNo
ATTENTION: You have selected influenza immunization. Please bring a photo ID and insurance card if you would like your flu vaccination billed to your medical insurance. Most insurance companies will pay for this. The self-pay price is listed below and dependent upon your age. If you will be self-paying for this option, please expect to add this dollar amount to your total lab charges as calculated above.

Flu vaccine for patients 6 months through 65 years = $40

Adjuvanted flu vaccine for patients over 65 years = $85
During your lab draw, if you have not received a COVID-19 vaccination to date, would you like to receive a COVID-19 Vaccination?*

YesNo
How would you prefer to receive your lab results?*

I will use my patient portal account to view my resultsI would prefer to have a paper copy of my results mailed to my address
Where did you hear about the health fair?*

A CRHC Employee or ProviderCRHC's WebsiteEmail ReminderFamily Member or FriendRadio or Newspaper AdvertisementI've Been Attending the Fair for YearsCRHC Employee Filling Out for a Patient
Important Information: Please Read.

Not all of this information applies to those participating at lab draws at their place of employment. Times, dates and locations of your lab draws will be communicated by your employer.
1) Appointments are needed for wellness lab draws, walk-ins will not be available. So please call 712-542-2176 after submitting this form to get an appointment on your preferred date/location. If you do not call after submitting this registration form, CRHC’s Scheduling department will reach out to you.

2) General Wellness Screen includes Cholesterol, Blood Sugar, Thyroid, Complete Blood Count, Electrolytes, and more.

3) For accurate results, a 10-12 hour fast is required for lab draws. Black coffee and water are ok. Please take all prescribed medication as normal.

4) Please pre-register 3 days prior to your chosen lab draw date, if possible. If not possible please call 712-542-2176 immediately to ensure time slots are available.

5) LAB RESULTS: Anyone with a patient portal will have access to their results within 3 business days of their draw. Anyone who opted above for a paper copy of their results via mail should allow seven business days to receive those results.

For questions about the lab draws or your registration, please call Kylee at 712-566-1684 or email at kcowling@clarindahealth.com
Please verify that you are human*
Should be Empty:

Fall Health Fair Sign Up Form

Important Information: Please Read.