Amberwell Health Fair Digital Consent and Voluntary Release Form
I voluntarily agree for myself and my dependents listed on this form to take part in a health fair event (“Health Fair”) and health screenings (“Screenings”) offered by Amberwell Health (“Amberwell”). I acknowledge that certain Screenings may require obtaining a blood specimen for the purpose of conducting laboratory tests on the specimen and that I may experience slight pain or a bruise at the puncture site. I hereby authorize Amberwell, its employees, agents, technicians, and any other practitioner performing services to obtain a blood specimen and conduct any necessary tests.
I understand that the results given to me concerning the Screenings are preliminary, for informational purposes only, and are in no way conclusive and must be compared with other test results by my personal healthcare provider for proper interpretation. I understand that the Screenings do not give rise to any duty on behalf of Amberwell, its employees, agents, technicians, or any physician to provide further interpretation, diagnostic tests or examinations, treatment, or any other medical services. I understand that the Screenings are not diagnostic and may fail to detect abnormalities that more definitive screenings would detect. In addition, I understand that it is possible that apparent abnormalities would be found to be normal by a more definitive screening.
I understand that for conclusive medical diagnosis of any condition, I need to be examined by my personal healthcare provider. I understand that it is my sole responsibility to a) provide the Screenings’ results to my personal healthcare provider; b) follow up with my personal healthcare provider on any potential abnormalities detected or not detected by the Screenings;
c) obtain a medical examination by my personal healthcare provider related to the Screening findings, or lack of findings; and d) carry out any other recommendations or advice regarding the Screenings’ results.
I recognize that there are certain inherent risks associated with the inflatable activities offered at the Health Fair and I assume full responsibility for personal injury to myself and my family members and further release and discharge Amberwell Health for injury, loss or damage arising out of my or my family’s use of or presence whether caused by the fault of myself, my family or other third parties.
I authorize Amberwell to disclose my and/or my dependent(s) name and city of residence as an attendee of this health fair and/or to have photographs, print materials, and audio or audiovisual recordings made of myself and/or my dependents. I understand that this information may be released by Amberwell to the news media or the public through broadcast media in print or on the internet which may be subject to re-disclosure.
I agree that Amberwell may contact me using the information provided at registration or at health fair booth activities regarding my and/or my dependent(s) health and health risks, health appointments, health events, health and health risks, and/or information on treatment options.
On behalf of myself and my heirs, successors, assigns and personal representatives, I hereby release, discharge, and agree to indemnify and hold harmless Amberwell Health and their respective employees, agents, affiliates, officers, directors, and representatives ("Released Parties") from any and all liability whatsoever for any and all claims, suits, damages, losses or injuries (including death) which may arise from my participation and/or my dependent(s) participation in the Health Fair, the disclosure of my protected health information as listed above, and/or from the information provided to me concerning Screenings and/or from any other information provided to me by Amberwell Health.
I have read or had read to me the acknowledgements set forth above and acknowledge that I understand the information in this form.