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Guard Your Heart

Cardi V CPL
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BHA Waiver & Consent Form
Procedure Description: I understand that as part of the screening process, a small sample of blood will be collected either by venipuncture or finger prick.Risks Acknowledgment: I am aware of the associated risks, which include but are not limited to: BleedingVessel injury Bruising Infection Disclaimer of Relationship: I acknowledge that participation does not create a patient/doctor relationship with BHA, its affiliates, or any healthcare providers involved. Emergency Authorization: In case of an emergency, I authorize BHA, its affiliates, or healthcare providers to arrange for necessary medical treatment. I agree to hold harmless all parties involved in the administration of such emergency care. I understand that I am responsible for any medical expenses related to the emergency treatments provided.Minor Consent: For participants under the age of 18, a signature from a parent or guardian is required. Communication Consent: By signing this form, I consent to receive periodic newsletters from BHA. I understand that these communications are part of my engagement with BHA and I can opt-out at any time.By typing my name below, I provide my consent for BHA to perform the screening as described above and waive any liability against BHA and their partners for the conduct of the screening.
Data is essential for keeping our bus operational and plays a critical role in helping us potentially save lives from heart attacks or strokes. We would like your permission to use your data, ensuring that no identifiable information will be included, for our white paper, research or policy/laws. Rest assured, we will never sell your personal information. Is it okay for us to use your data in this way?
Would you like to become a member BHA's "Heart Guard Champion" advocacy program? This program is dedicated to the principles of justice, righteousness, and equity. Our mission is to combat injustice, inequity, and unrighteousness within the healthcare system and beyond. We invite you to join us in our fight by engaging in policy reform, addressing systemic issues, and raising your voice for our patient community. Together, we can create a more just and equitable world. Join Heart Guard today and be a part of the change!
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Guard Your Heart

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BHA Waiver & Consent Form