Health Fair Form

Health Fair Sign Up Form
Patient Name*

First NameMiddle NameLast NameSuffix
Patient Gender*
Patient Birth Date*

MonthDayYear
SSN- Last 4 Digits *
Patient E-Mail
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Choose all that apply. Payment will be taken at the time of service*

Wellness Screen (22 blood tests) - $35Prostate Screen (PSA- MEN ONLY) - $20Hemoglobin A1C (Diabetic) - $15
Amount Due in $: *
This is due at the time of service
Important Infromation for Lab Draws at George C. Grape Community Hospital
1- Please complete the form so our staff can prepare for your lab draw and have you pre-registered. If you are unable to attend this day, please contact the hospital to make it up by appointment with our Labratory.

2- General Wellness Screen includes: Blood Count, Complete Metabolic Profile, Lipids (Cholestrol and Triglycerides) and Thyroid Screen (TSH).

3- Please pre-register up to the week of the lab draw date- the form will close Monday, September 22nd. Please call 712-382-1515 to register after this form has closed.

4- Payment is due at the time of service. Please bring cash or check for payment of the lab draws.

RESULTS: Results will be mailed to the address placed above. Please allow 7 business days to recieve the results. Results are not reviewed by your Primary Care Provider. If you have abnormal values, our Labratory will contact you directly. Please consult and follow up with your Provider as soon as possible if this arises or if you have questions or concerns relating to your results.

For questions about your lab draw, the event, or general questions, please contact Tammy Oakes or Mallory Nothwehr at 712-382-1515 or email toakes@grapehospital.com or mnothwehr@grapehospital.com
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Health Fair Sign Up Form