2026 Archuleta Health Fair & Expo Registration Form

First Name

Last Name

Email

example@example.com

What is your preferred language?

Other

Date of Birth

Date

Gender (information required for the labs)

Other

Mobile Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Landline Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Select your appointment window. If you are not getting labs please select the last option "I am not getting lab services." Please arrive at the beginning of your appointment window. Individuals that arrive past 9:30 may not be able to be seen. Individuals signing up for labs need to fast (not eat or drink anything except water) for 12 hours prior to getting blood drawn.

Release and Waiver of Liability Agreement

I request and grant permission to Healthy Archuleta and Archuleta County, and the volunteers and organizations participating in the Archuleta Health Fair and Expo medical screenings, to perform certain health screenings for me. I understand that my personal identifying information and test results will be confidential, with the exceptions stated below. If I choose to have blood analysis at the Archuleta Health Fair and Expo, I grant the volunteer phlebotomist permission to draw a blood sample, and I grant the contracted laboratory permission to perform a set of standardized laboratory screenings on my blood sample. I understand that in order to conduct the blood analysis, Healthy Archuleta and Archuleta County may disclose information from this registration to the contract laboratory and that Healthy Archuleta and the Archuleta County Public Health Department will deliver the blood analysis to me via the Labcorp patient portal. I understand that there is no follow-up from a medical provider, and participation in the blood draw and subsequent screening does not include a review by a medical professional or a follow-up visit. IF I want my labs reviewed with a medical provider, I will have to schedule an appointment and cover the cost of the visit. You will be notified urgently if any of your lab results are in a critical or life-threatening range.

Venipuncture (drawing blood from a vein in your arm) is a very safe procedure. However, there is a small risk of complications, including but not limited to bruising, infection, blood clots, etc. By signing this consent, I agree that I understand that these risks exist and that the phlebotomist, the supervising physician, Healthy Archuleta, and Archuleta County are not responsible for any care that might be required as a result of these complications.

I understand that Healthy Archuleta and Archuleta County will disclose information from this registration to the partner or contracted provider. In the event of an accidental needle puncture or other biohazard exposure, I authorize additional precautionary testing of the sample. I further consent and allow Healthy Archuleta and Archuleta County Public Health Department to disclose my individual results to a Colorado Regional health information exchange such as Quality Health Network or Colorado Regional Health Information Organization. I understand that de-identified data can be used by Healthy Archuleta and Archuleta County to further the work of each organization; my name and any personal information will not be disclosed, and data can be used for monitoring progress toward population health outcomes.

NOTICE TO ALL MEDICARE PART B BENEFICIARIES: I understand that should I go to my physician and/or healthcare provider. Medicare allows:

- a screening occult blood test once every twelve (12) months;

- screening cholesterol, triglycerides, and HDL tests once every five (5) years;

- two (2) screening glucose tests per year for individuals diagnosed with pre-diabetes;

- one (1) screening glucose test per year for individuals previously tested who were not diagnosed with pre-diabetes, or who have never been tested;

- screening Prostate Specific Antigen test (PSA) once every twelve (12) months for males who are over fifty (50) years of age.

MEDICARE WAIVER: I have been informed and understand fully, that NO claim will be filed on my behalf, NOR will I file a claim with Medicare or my Supplemental Insurance. I voluntarily take full financial responsibility for the screening(s) I have ordered, even if Medicare would have paid for any or all of these tests, had I gone to my physician or healthcare provider. I, therefore, of my own will, refuse to authorize the laboratory or health fair provider of services to submit a claim to Medicare on my behalf.

Information collected by Healthy Archuleta (80 CR 600/PO Box 3995, Pagosa Springs, CO 81147). Healthy Archuleta is a 501(c)(3) organization that values your privacy and will not rent or sell your information to outside parties. This authorization allows us to contact you about services to complement actions you and your health care provider may already be taking to help you own your health.

I authorize Healthy Archuleta to use and disclose my protected health information to market prevention and/or screening services provided by Healthy Archuleta and/or our authorized service provider(s). For the purposes of this Authorization, protected health information includes information received by Healthy Archuleta through screenings requested as part of this Online Registration process; and/or information disclosed by the participant to Healthy Archuleta on questionnaires or in writing.

Recognizing that Healthy Archuleta is a 501(c)(3) non-profit organization, I authorize Healthy Archuleta to use my protected identifying information to contact me for fundraising purposes.

I understand the following:

Healthy Archuleta may withhold service if I refuse to sign this Authorization.
I may change my mind and revoke this Authorization at any time, however, my revocation will only apply to future uses and disclosures of my information and will not apply to any uses or disclosures that Healthy Archuleta made prior to receiving my revocation.
I may revoke this Authorization by sending a written request to Healthy Archuleta, PO Box 3995, Pagosa Springs, CO 81147
Information used or disclosed pursuant to this Authorization may be re-disclosed by the individual and no longer be subject to HIPAA.
I have a right to receive a copy of this Authorization. Without my express revocation, this Authorization will automatically expire upon satisfaction of the need for disclosure, but in any event, will expire two (2) years from today’s date, unless otherwise specified.

I have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability and a contract between me and Healthy Archuleta and Archuleta County, and I sign it of my own free will.

Signature

Registration

Health Fair Registration

$5.00

CMP, CBC, Lipid, A1c, TSH

Individuals signing up for labs need to fast (not eat or drink anything except water) for 12 hours prior to getting blood drawn

$20.00

PSA (for men only)

Men getting their PSA checked should be advised to stay off bicycles, horses, and sexual activity for 48 hours prior to getting blood drawn

$6.00

Vitamin D

Individuals signing up for labs need to fast (not eat or drink anything except water) for 12 hours prior to getting blood drawn.

$16.00

Children, Health Fair Volunteer, Vendor that has already paid the registration fee

Free Quantity

Optional donation to support health and food access work in our community

You can donate in increments of 10 dollars. If you want to give $100, please select a quantity of 10.

$10.00 Quantity

Enter coupon

Total

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Did you attend the 2023 Archuleta Health Fair & Expo?

Did you attend the 2024 Archuleta Health Fair & Expo

Did you attend the 2025 Archuleta Health Fair & Expo

Which of these did you find most helpful? Please select all that apply.

Why are you interested in attending this year's health fair?

Do you have a primary health care provider that you see for your annual check ups?

At which of these locations is your primary health care provider?

Other

When did you last have an annual check up?

Do you currently have health insurance coverage (private, Medicaid, Medicare, other)?

In general, would you say your health is

In the past week, on how many days have you done a total of 30 minutes or more of physical activity, which was enough to raise your breathing rate? (This may include sport, exercise and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that may be part of your job.)

In the past 7 days, how many servings of fruits or vegetables did you eat each day?

Please select your race/ethnicity (check all that apply)

How did you hear about this year's Health Fair?

2026 Archuleta Health Fair & Expo Registration Form

Registration*

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