12th Anniversary Health Fair Registration Form

Lab Test / Consultation Waiver

Name *

First

Middle

Last

Date of Birth *

Phone *

Email *

Address *

Address Line 1

City

State

Zip Code

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.
It is my responsibility to make an appointment with the Lab Corp. service center and get blood drawn. I can retrieve the lab result from the Lab Corp web site.

TIPS physicians will contact me within approximately two weeks to discuss the results and my concerns.

These free consultations are only to help me guide on the future care of my health and any medical condition. These consultations are definitely 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 omission,
during the whole process of this health fair.

Confirmation *
I have read the above information and understand it fully.
The cost of the lab test is non-refundable. We will send you the information for the lab test date and for physician consultation. Cost is $20 per patient.

Lab Cost *
Price: $ 20.00