Stroke Screening Appointment Form

2025 Stroke Screening

Our Stroke Screening event will be held on April 25, 2025 from 8 a.m. to 3 p.m. To schedule an appointment, please fill out the information below. You can also schedule by calling 812-885-3336. This event will include lipid profile, A1c, blood pressure, BMI, carotid artery screening and atrial fibrillation. Educators, registered nurses and a dietician will also be offering valuable information and hand-outs describing the different ways to decrease the risk of stroke.
Appointment Scheduler
Please select an appointment time for the Stroke Screening on April 25. All times are Eastern.*
If no appointment times are available, would you like to be added to our waitlist in case there are cancellations? Those on the waitlist will be added in order if cancellations occur.

Yes, please go ahead and register me on the wait list.
Contact Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Consent for Blood Draw

The free blood draw will consist of a lipid profile and an A1C. If you have a Good Samaritan primary care provider or if your non-Good Samaritan provider is included in your electronic health record, they will automatically receive a copy of your results.
Do you have a MyChart account? (Patients who have a MyChart account will receive their results electronically through MyChart and will not be mailed paper results).*

YesNo
If you would like to sign up for a MyChart account, you can CLICK HERE. With MyChart you will have access to your lab results as soon as they are entered into our electronical medical record system. Also with a MyChart account, you can communicate with your doctor, manage your appointments and request prescription refills.
Informed Consent for Blood Draw
- I authorize Good Samaritan to obtain blood from me using the venipuncture method as the screening/test requires.
- I understand that the test is only an indicator of potential health problems and that it is not a diagnosis or a substitute for physician care. I am aware that it is my responsibility to contact my general physician for an appointment to discuss the significance of my results.
- I further understand that this information is confidential and will not be shared with others except anonymously for statistical or research purposes. I agree to let Good Samaritan exchange information with my Good Samaritan physician or the physician listed above.
- I release Good Samaritan from all liability.
- I acknowledge that a copy of the Notice of Privacy Practices is available to me upon request. (Information Privacy" We [and our Medical Staff] will use and disclose your personal health information to treat you and for other health care operations. Health care operations generally include those activities we perform to improve the quality of care, such as follow up by a nurse regarding test results and/or patient satisfaction. We have prepared a detail NOTICE OF PRIVACY PRACTICES to help you better understand our policies in our facilities and have copies available for distribution).
Please type your first and last name as your electronic signature for consent to have your blood drawn at the Stroke Screening event on April 25, 2025.*

First NameLast Name
Date*

MonthDayYear
Date
THIS SECTION TO BE COMPLETED BY GOOD SAMARITAN STAFF

Patient Education: O Verbal O Written

Patient Identification: O Name acknowledgement O Written name verification

O Witnessed Written Date of Birth O Date of Birth Verification

Tests performed:

O Lipid Profile O A1C

________________________________ _____________

Lab Personnel Signature Date
Should be Empty:

2025 Stroke Screening

Appointment Scheduler

Contact Information

Consent for Blood Draw