Prepaid General Health Fair Lab Testing Form - Cardiac/Pulmonary Rehab Office in Hastings

Prepaid General Health Fair Lab Testing Form - Cardiac/Pulmonary Rehab Office in Hastings

Please fill the entire form below to register. Make sure to hit submit at the bottom after choosing a date and time. You will receive an email confirmation.
Legal Name

First NameLast Name
Date of Birth

MonthDayYear
Gender
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Primary care provider (It is your responsibility to forward results to your provider.)
Which tests would you like to order. Check all that apply.
My results
By signing below, I acknowledge the following:
- I release Mary Lanning Healthcare from all claims, demands and assertions of liability engendered by myself or my representatives, arising from or based upon Mary Lanning Healthcare or its activities (including tests, omissions, errors, disclosures or nondisclosures) which may arise from data obtained as required.
- I hereby request and authorize Mary Lanning Healthcare for venipuncture as required for the purpose of performing blood test determination.
- I understand that my lab results will not be sent by Mary Lanning Healthcare to my primary care physician.
- I agree to Personal Disclores of my lab resuts to Electronic Health Record (EPIC), or to my email, if either was requested above.
- I have prepaid and I hereby restruct this service from being filed with my insurance company for payment by me or by Mary Lanning Healthcare.
Signature (Draw your name with your mouse.):
Payment type (due upon arrival):
Please do not sign the "Decline Prepaid" box unless you want us to submit the costs of this bloodwork to your insurance, rather than paying with cash or check. Just continue on to selecting an appointment date and time. Don't forget to hit submit at the bottom of the form.
Decline Prepaid: I acknowledge that I have been informed of the special prepaid process and I hereby decline to participate in this offer. I request that my service today be billed at regular charges to my insurance company and will require a physician order.
Insurance company (if applicable):
Signature (Draw your name with your mouse.):
You must choose an open date.

We want to serve as many people as possible with our health fairs. However, we are limited by the number of staff members available.

If the date you wish to attend is full, the boxes will be grayed out. Please do not attempt to register without selecting a date. We may not be able to honor appointments made without an open date or time.

Please choose an alternative date if possible.
Thursday, August 27
Thursday, September 10
Thursday, September 24
Thursday, October 8
Thursday, October 22
Thursday, November 12 - LAST ONE UNTIL FEBRUARY
Should be Empty:

Prepaid General Health Fair Lab Testing Form - Cardiac/Pulmonary Rehab Office in Hastings

You must choose an open date.