Harper County Health Fair Registration

Highway To Health Registration

Patterson Health Center will provide lab draws at a greatly reduced price. Please remember that the draws are a fasting lab, but water, tea or coffee (without sweetener or creamer) are allowed.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*

Area CodePhone Number
Medical Provider
Are you or your spouse an employee, board member, or member of the Harper County Health Foundation?*

YesNo
Would you like a flu shot?*

YesNo
Would you like a follow up appointment to discuss results of your lab tests?*

YesNo
Which location is most convenient?*

Certain Waivers under HIPAA. (a) Patient acknowledges that neither Group nor Physician guarantees that communications with Physician using electronic mail ("e-mail"), facsimile, video chat, instant messaging, and cellular telephone are secure or confidential methods of communications. Accordingly, Patient expressly waives Group’s and Physician’s obligations under the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. § 1320d et seq.), as amended by the Health Information Technology for Economic and Clinical Health Act of 2009, and all rules and regulations promulgated thereunder (collectively, "HIPAA"), and other state and federal laws and regulations applicable to the use, maintenance, and disclosure of patient-related information, to guarantee confidentiality with respect to correspondence using such means of communication.
By ordering a self-ordered test, I understand that I cannot turn this claim into an insurance company. I understand that the results will be mailed directly to the address provided above. It is my responsibility as the patient and self-order to share the results with my physician or provider. Due to HIPAA, Patterson Health Center will not release the self-ordered test results to anyone but the patient, however results will be in your medical records at PHC.

Please acknowledge you understand the above statement by signing below.
Signature*

Clear
Patient Name*
Today's Date*

MonthDayYear

Patterson Health Center
Conway Springs Appointment*
Staff/Board/Spouse Lab Draw Appointment*
Are you:*

EmployeeEmployee SpouseBoard MemberFoundation Board MemberFoundation Employee

Choose your tests

Please mark your desired test(s) and submit form by Oct. 11, 2024. There is a $5 registration fee after Oct. 11.
Choose which labs you want:

Lipid Profile - Tests cholesterol, triglycerides & HDL. Free for 60+, $10 for under 60.CBC - Tests white & red blood cell count, hemoglobin & platelet count. Free for 60+, $10 for under 60.CMP - Tests 14 things like blood sugar, electrolytes, liver function, etc. & TSH - Thyroid Stimulating Hormone: Measures thyroid function. Free for 60+, $15 for under 60
60+ lab total
A1C - Measures diabetic control: gives average blood sugar for the past 3 months. $10PSA (men only) - Prostate Specific Antigen: Screens for prostate cancer. $10Vitamin D - Promotes calcium absorption, prevents osteoporosis and is important to the immune system. $25
other lab total
Subtotal
Credit Card fee
Total
Total

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Highway To Health Registration