2026 Health Fair Screening Registration Form for Fair

2026 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 from April 20th to May 1st (Monday–Friday, 8 AM–4 PM) OR the Health Fair on Saturday, April 25th 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 20th to May 1st (Monday–Friday, 8AM–4PM).

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.Format: (000) 000-0000.

Provider Name

Provider Phone Number

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

$49 Lab Package ($553 value)Includes a CBC, CMP, & 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. Lipid Panel – 4 tests to help assess cardiovascular disease risk; to monitor and in treatment.

$15 CBC (Complete Blood Count) CBC – To screen for, and monitor diseases and conditions that affect blood cells, such as anemia, infection, inflammation, bleeding disorders or other potential abnormalities.$20 CMP (Comprehensive Metabolic Pane) CMP – 14 tests to screen and/or monitor certain conditions, such as blood chemistries and kidney, or liver-related problems, among other things.$20 Lipid Panel Lipid Panel – 4 tests to help assess cardiovascular disease risk; to monitor and in treatment.$15 Hemoglobin A1CHemoglobin A1C – To help in the diagnosis of diabetes and monitor status of diabetes for treatment decision$15 TSH (Thyroid-Stimulating Hormone) TSH – Screens for thyroid disorders; and used to monitor treatment of hypothyroidism/hyperthyroidism.$15 PSA (Prostate-Specific Antigen) PSA – Prostate Cancer Screening for men aged 50+ years.

Signature for Lab Testing and Notice of Privacy Practices*

Today's Date*

Date