Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastDate of Birth (Minimum age 18 years) *Gender *MaleFemalePhone *Email *Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDo you need Doctor's consultation in person? (Health Fair Day is on May 20, 2023) *YesNoSelect Specialist Doctor for Consultation (select any 2 choices)Primary care (Internal medicine/Family practice)CardiologyNeurologyGastroenterologyPulmonologyEndocrinologyPediatricsRheumatologyObstetrics/GynecologyPsychiatryGeneral SurgeonOrthopedic surgeonHematology/OncologyInfectious diseaseEar, Nose and Throat specialistOphthalmologistDermatologyPain ManagementUrologyNephrology I understand that TAHTS and TIPS are conducting the Health fair as a voluntary service to the community. The panel of blood tests is the same for all. I am responsible for making an appointment with the Lab Corp. service center between May 1, 2023 to May 15, 2023 and getting blood drawn. I can retrieve the lab result from the Lab Corp website or collect it on Health Fair Day. These free consultations are only to help me guide on the future care of my health and any medical condition. These consultations are not a substitute for my responsibility of getting proper medical care through the relevant medical specialist. No medicine will be prescribed. I agree to hold TAHTS, TIPS, and its volunteers (including physicians) harmless and free of any liabilities, for any unintentional errors, delays, or omissions,during the whole process of this health fair. The cost of the lab test is non-refundable. We will send you the information for the lab test date. Cost is $25 per patient.Confirmation *I have read the above information and understand it fully.Lab Cost *Price: $ 25.00Donation to TAHTS (Enter any amount you wish to donate)We appreciate your support.Submit