Memorial Hospital Community Health Screening Lipid Panel, A1C, Vision and Hearing

Please register on or before November 9th. 

Fasting for 10-12 hours is recommended.

What: Health Screenings 

• A1c
• Lipid Panel
• Tanita Scale
• Vision
• Hearing

This screening includes a complimentary breakfast at the hospital's courtyard cafe. 

Date: Wednesday, November 12 (Only two (2) openings for each session from 7:30 to 9:30 are available)

Location: Memorial Hospital Health & Wellness Center Conference Room, located at 1454 N. County Road 2050, Carthage, IL 62321

Understanding more about your screenings

• Vision Screening – Vision screening is as simple as having your picture taken. Our mobile screener has proven accuracy in detecting vision problems.
• Hearing Screening – Hearing screening lasting 1-2 minutes to check auditory sensitivity in both ears with proven accuracy.
• The sample for the Lipid and A1C Screening is collected from blood from the finger (finger stick).
• Fasting for 10-12 hours is recommended for a lipid screening.
• Being well-hydrated is important for the best sample collection. Black coffee and water are acceptable.
• Applying lotion to the hands can affect sample results and is NOT recommended.

Consent and Waiver of Liability

1. Consent to Participate. I acknowledge and agree that I am voluntarily participating in Memorial Hospital’s heath fair screening. My involvement is as a participant and not as a patient. I further acknowledge and understand that the screening/testing is limited in nature and is not a substitute for seeking medical treatment or follow up with a health care provider.

2. Types of Screenings. I acknowledge and understand that the health fair is offering the following screenings/testings: (NOT INSURANCE BILLABLE)

• LIPID PROFILE
  Includes cholesterol, triglyceride, high-density lipoprotein (HDL), low-density lipoprotein (LDL)
• HEMOGLOBIN A1C:
  A blood test that provides an index of a person’s average blood glucose concentration during the previous 3-month period. Used to monitor patients diagnosed with diabetes.
• Hearing Screening
• Vision Screening
• Tanita Scale
  TOTAL DUE: $ 25.00

3. Consent for Blood/Body Fluid Testing; Risks. I acknowledge and understand that by participating in the health screening, I will be required to submit to blood testing. I understand that I may experience slight pain or a bruise at the puncture site. There is also the risk of an accidental needle puncture or other biohazard exposure. In such a case, I authorize additional precautionary testing of the sample.

4. No Health Care Provider/Patient Relationship. With respect to my participation in the health screening, I acknowledge and understand that the health care provider is not my personal health care provider and is offering the screenings/testings, recommendations, and self-care solely for my educational purposes. I understand that this means that I do not have a health care provider/patient relationship for purposes of the results of the screenings/testings and I must contact my personal health care provider if I have additional questions or require follow up after the health fair.

5. Preliminary Results. I further acknowledge and understand that the screening/testing results provided to me at the health fair are preliminary in nature and are in no way conclusive. I further understand that the screening/testing is not diagnostic and it could fail to detect certain abnormalities that might be detected by more definitive screenings/testings; or it might detect apparent abnormalities that would be found normal with more conclusive testing. For a conclusive medical diagnosis of any medical condition I may have, I understand that I need to be examined by my personal health care provider.

6. No Guarantees; Recommendations. The Hospital, its employees, agents, officers, members, and health fair participating health care providers make no claims, representations, or guarantees with respect to the accuracy or precision of screenings/testings due to the limited nature of the evaluation provided. I acknowledge and understand that it is my sole responsibility to follow up on any recommendations that are made to me during the screening/testing and obtain follow up evaluation, testing, and medical diagnosis from my personal health care provider.

7. Consent to Share Results. Screening results are provided to participants at the time of the screening. Results will not be sent to your provider, reviewed by a health care provider, or placed in your medical record. It is your responsibility to review the results with your health care provider.

8. Confidentiality. I understand that the Hospital will maintain the confidentiality of the screening results in accordance with the Hospital’s Notice of Privacy Practices and applicable state and federal laws.

To read our privacy policy, please click here: Privacy Policy.

9. Waiver and Release of Liability. In exchange for being given free or low-cost health screenings/testings, I release, discharge, and hold harmless, the Hospital, its employees, agents, officers, members, and health fair participating health care providers from any and all claims, demands, losses, damages, or injuries, arising from, or based in whole or in part on, my participation in the Hospital’s health fair/ testing, including, but not limited to, the results of the health fair screenings/testings; any statements made to me by any health fair agent, employee, or volunteer; nondisclosure to me of any information; or my receipt or non-receipt of any information from the health fair.

Health Fair Participant Acknowledgement: I have read this form, or have had it read to me, and understand the contents of this form. I believe that I have the knowledge upon which to base consent to participate in Memorial Hospital’s health fair/screening. All questions have been answered to my satisfaction. I hereby give consent to the screenings indicated above.

Cost is non-refundable. If the screening event is cancelled, it will be rescheduled to a later date.