Pre-Registration - Cash or Check | North Canyon Network of Care

Personal Information
First Name*
Middle Initial*
Last Name*
Gender/Sex*
Age*
Date of Birth*
MM slash DD slash YYYY
Phone Number*
E-mail Address*
Mailing Address*
Street Address City State ZIP Code

Primary Care Physician
Do you have a Primary Care Physician?*
- Yes
- No
What is the Full Name of your Primary Care Physician?*
Health Fair Test Results Available Through Patient Portal
Health Fair test results will be available on the Patient Portal within 48 hours. Sign up today for the fastest access to your results.
Have you signed up for the patient portal?*
- Yes. I have a patient portal through North Canyon.
- No. Please sign me up for the patient portal.
Great! We will send your results through the Patient Portal.
No problem, please enter your email address below and we'll send you an invitation to the Patient Portal...
NOTE: If you do not sign up for patient portal access then your results will be mailed to you and this can take up to 10 business days.

LAB Registration
Mark "Yes" on the tests you want to receive:
Lab Work Specials (CBC, Comp Metabolic Panel, Lipid, TSH, HGa1C) - $45*
A broad screening tool to evaluate organ function and check for conditions such as a coronary heart disease, diabetes, liver and kidney disease. Hemoglobin A1c now included in panel. 12 hour fast required.
- Yes
- No
Lab Work Specials Profile
Price:
PSA (Recommended for men 40 and over) - $15*
A screening test for males to detect prostate cancer.
- Yes
- No
PSA
Price:

North Canyon Contact List
Sign up for our contact list*
- Yes, I would like to to receive information from North Canyon regarding next years health fair and other future events.
- No, please do not sign me up for the email list.

Lab Work Specials Blood Work Consent & Release Form
The undersigned hereby requests that health screening be performed for me by the organization and individuals participating in the Lab Work Specials under the direction of North Canyon Medical Center. I understand that all screenings will be performed without charge to me whatsoever, expect for the optional blood work.

I hereby release the major sponsors, organizations and individuals participating in the Health Fair from any and all liability including any matter or thing committed or omitted which may arise during blood drawing, vaccination, or other screening or from the data derived there from.
It is understood that:
1. The data derived from such screening is to be considered as preliminary only and is in no way conclusive.
2. The responsibility for initiating any follow-up examinations for results outside limits identified at the Health Fair lies with me as the person responsible for my own health and not with any participating organization.
3. Lab Work Specials volunteers will have access to my screening results for the sole purpose of ascertaining the identity of the person tested and determining the correct order for filing/mailing such information.
4. No other individual or agency will have access to my individual screening results without the express written permission from me. Aggregate data may be used to report and research purposes.
5. Insurance cannot and will not be billed for the laboratory services.
I have read and understand the above statements.
Signature*
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Pre-Registration – Cash or Check

Event Dates & Locations

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Personal Information

Primary Care Physician

Health Fair Test Results Available Through Patient Portal

NOTE: If you do not sign up for patient portal access then your results will be mailed to you and this can take up to 10 business days.

LAB Registration

North Canyon Contact List

Lab Work Specials Blood Work Consent & Release Form

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