Events

I request and grant permission to the volunteers and organizations participating in the Middle Park Health (MPH) Community Health Fair to perform certain health screenings for me. I understand that MPH will treat information received from me in a confidential manner. If I choose to have blood analysis, I grant the volunteer phlebotomist permission to draw a blood sample, and I understand that venipuncture (drawing blood from the vein) has its own risks and may cause bruising or pain. I grant the MPH Laboratory permission to perform a set of standardized laboratory screenings on my blood sample, and I understand that MPH will mail the blood analysis results to me. In the event of an accidental needle puncture or other biohazard exposure, I authorize additional precautionary testing of the sample. I acknowledge that my participation in the MPH Community Health Fair is completely voluntary, and at no time is MPH or its agency establishing a provider-patient relationship with me. I understand that health screenings may be performed at no charge to me, except for the optional blood analysis and/or any other special screenings for which a fee is charged. Third-party payors will not be billed by MPH. I also understand that health screenings can only provide certain preliminary measurements and cannot be relied upon to diagnose the existence or absence of any medical condition. I understand that my participation in the MPH Community Health Fair is not a substitute for examination by a medical doctor and that I alone am responsible for obtaining, from a doctor or other qualified health care provider, medical information or services concerning: 1) Any aspect of my health, and 2) any information I may receive from MPH. I further understand that MPH does not guarantee the accuracy of the results of any health screenings and is not responsible for advising me concerning the results of any health screenings. I agree that I may be contacted by MPH at a later date. Information collected at MPH is sole property of MPH. My information will not be released without my written permission. In return for being given free or low-cost health screenings, I release MPH and organizations participating in the MPH Community Health Fair and all of the employees, officers, directors, trustees, volunteers, or agents of the foregoing entities, from any and all claims, demands or assertions of liabilities which I or my representatives might make, including claims of negligence, arising from or based in whole or in part on, the nondisclosure to me of any information, any event or circumstances that may occur while I am present at the MPH Community Health Fair, or any other act or omission of MPH, and organizations sponsoring or participating in the MPH Community Health Fair. It is my express intent that this release will bind the members of my family, my spouse, my heirs, assigns, agents, personal representatives, dependents and all others who may act on my behalf. I am 18 years of age or older, and I have read, understand, and agree to the foregoing Consent and Release.