Piedmont Triad Church
Community Health Fair

Health Screening Consent and Voluntary Release Form

I,  (stated above)_(patient’s name), voluntarily agree to take part in the
community health fair and health screenings offered by the Piedmont Triad Church (“PTC”).
The health screenings may include screenings for diabetes, hypertension and hyperlipidemia
and related lab tests (“Screenings”). I acknowledge that certain Screenings may require
obtaining a blood specimen for the purpose of conducting laboratory tests on the specimen. I
understand that if blood is obtained from a finger stick, I may experience slight pain or a bruise
at the puncture site. I hereby authorize the PTC, its employees, volunteers, agents 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
information purposes only, and are in no way conclusive. The results must be compared with
other test results by my personal physician for proper interpretation. I understand that the
Screenings do not give rise to any duty on behalf of the PTC, its employees, volunteers, agents
or any other practitioner 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 could 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 physician. I understand that it is my sole responsibility to:
1. Provide the Screenings’ results to my personal physician,
2. Follow up with my personal physician on any potential abnormalities detected or not
detected by the Screenings and to obtain a medical examination by my personal
physician related to the Screening’s findings, and
3. Carry out any other recommendations or advice regarding the Screenings’ results.
On behalf of myself and my heirs, successors, assigns and personal representatives, I hereby
release, discharge, and agree to indemnify and hold harmless the PTC, their respective
employees, agents , affiliates, officers, directors, volunteers and agents and representatives
from any and all liability whatsoever for any and all damages, losses or injuries (including death)
which may arise from my participation in the PTC Community Health Fair and/or from the
information provided to me concerning the Screenings and/or from any other information
provided to me in connection with the PTC Community Health Fair.
I have read or had read to me the acknowledgements set forth above and acknowledge that I
understand the information in this form.