2025 Health Fair Screening Registration Form for Fair

2025 Health Fair Screening Registration Form

I give Cibola General Hospital permission to draw blood samples from me. These samples will be used to perform specific standardized laboratory procedures to determine levels of certain chemicals and substances in my body.

This test is being performed at my request. I understand that my blood sample will be collected at Cibola General Hospital April 14th to May 2nd (Monday–Friday, 8 AM–4 PM) OR
the Health Fair on Saturday, April 26th 8AM to 11AM at Grants High School.

Attention: New Lab Drawing Option Available! We’re excited to offer a new way to get your lab work done:
1. At the Fair: Labs will still be drawn at the fair as usual.
2. At the Hospital: Now, you can also have your labs drawn at the hospital from April 14th to May 2nd (Monday–Friday, 8 AM–4 PM).

If you choose the hospital option, please call (505) 287-5290 in advance to schedule your appointment. Results will available in the patient portal, be sent to my Primary Care Provider, if I list one below, and/or the results will be mailed to me and become a part of the legal medical record at Cibola General Hospital.

Name*

First NameLast Name

Date of Birth*

Date

Gender*

Ethnicity*

Tribal Affiliation

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number*

Please enter a valid phone number.

How did you hear about these offers?

Provider Name

Provider Phone Number

Please enter a valid phone number.

Type a question*

$29 Bronze Package ($267 value) Includes a CBC & CMP (CBC – To screen for, and monitor diseases and conditions that affect blood cells, such as anemia, infection, inflammation, bleeding disorders or other potential abnormalities. CMP – 14 tests to screen and/or monitor certain conditions, such as blood chemistries and kidney, or liver-related problems, among other things.**Fasting Suggested$49 Silver Package ($351 value) Includes a CBC, CMP, & Hemoglobin A1C. (CBC – To screen for, and monitor diseases and conditions that affect blood cells, such as anemia, infection, inflammation, bleeding disorders or other potential abnormalities. CMP – 14 tests to screen and/or monitor certain conditions, such as blood chemistries and kidney, or liver-related problems, among other things. Hemoglobin A1C – To help in the diagnosis of diabetes and monitor status of diabetes for treatment decision.**Fasting Suggested$89 Gold Package ($512 value) Includes a CBC, CMP, Hemoglobin A1C, Lipid Panel. (CBC – To screen for, and monitor diseases and conditions that affect blood cells, such as anemia, infection, inflammation, bleeding disorders or other potential abnormalities. CMP – 14 tests to screen and/or monitor certain conditions, such as blood chemistries and kidney, or liver-related problems, among other things. Hemoglobin A1C – To help in the diagnosis of diabetes and monitor status of diabetes for treatment decision. Lipid Panel – 4 tests to help assess cardiovascular disease risk; to monitor and in treatment.**Fasting Required

Add either/or both tests below for an additional $15 each to any package.

Add TSH(Thyroid) test ($116 value)Add PSA (Prostate Cancer Screening) – for men aged 50+year ($108 value)

Signature for Lab Testing and Notice of Privacy Practices*

Today's Date*

Date