Health Fair Toolkit Page 26
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35Clinical Forms
SAMPLE SCREENING CONSENT FORM
Name (Last, First, M.I.):
Date:
Address:
City:
State:
Zip Code:
Phone:
Social Security #:
Date of Birth:
I am requesting this test for screening purposes only and understand that only my doctor
may diagnose my condition. Individuals who are symptomatic or otherwise at high risk
should be seen for specific testing in addition to this screening. As a participant in this
screening, I hereby waive any and all claims against the sponsors of this screening, its
employees, agents, and medical staff connected with or arising out of services rendered in
connection with this screening.
Signature:
Date:
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