WELLNESS SERVICES (Labs/Injections Only)
Number and Street City State/Zip
Telephone: Date of Birth: Sex: M / F
I hereby consent to the screening(s) checked below:
o Adacel – TD AP
o Tetanus – tD
o Polio – IPOL
o Menactra (Meningitis)
o Hepatitis A (Adult)
o Hepatitis B (Adult)
o Twinrix (Hep A & B)
o Typhoid (Vi) injection
o Yellow Fever
o Viamin 812
o Other testing
o Urine Pregnancy
o Lipid panel (Cholesterol)
o T hyroid Panel (TSH, F-T4 )
o PSA (Prostate Test)
o Arthritis Panel (ANA, ESR, RhF)
o Hepatitis A & B Titer (Both Tests)
o Hepatitis C Test
o Hepatitis A Qr Hepatitis B Titer (Single)
o Fatigue Panel (CBC, TSH, ESR, 812 , Folate, Fe)
o Men’s Health Panel (CBC/CMP/PSA)
o Women’s Health Panel (CBC/CMP/Thyroid)
o Varicella Titer
o Vitamin D Level
D MMR Titer
o Lead Level
o Blood Type
o HbAIC – Average Blood Sugar
o Glucose (Accucheck)
o UDS (rapid in-house) non-DOT
o Uric Acid Level (Gout Test)
o Serum Pregnancy
I understand that:
1. If a screening or lab is performed, results are to be considered preliminary only and do not constitute a diagnosis of any medical condition.
2. The responsibility for initiating a follow-up examination to confirm abnormal screen results, obtain advice, or receive treatment is mine and not that or my provider or any organization associated with this screening.
3. I understand there is a provider available, for an additional charge, to discuss the results and/or vaccines I receive.
4. If I received vaccines, I agree that I have read the vaccine information sheet and understand the risks and side effects of these injections.
5. ALL WELLNESS SERVICES INCLUDING LABS AND IMMUNIZATIONS ARE CASH PAY SERVICES AND NOT FILED TO INSURANCE.
NOTE: All lab results are given directly to patients only via pick up in office or by mail.
Patient Signature: Today’s Date: