Health Fair Patient Registration

*Please select the tests that you would like to have performed:*

Multiphasic Blood Screening: $45
PSA (Prostate Specific Antigen) Screening: $15
Hemoglobin A1C Screening: $15
TSH (Thyroid Stimulating Hormone) Screening: $15
Vitamin D Screening: $20
Vitamin B12 & Folate Screening: $15
Blood Typing: $10

*First Name

*Last Name

*Middle Initial

*Email

*Date of Birth

*Sex

Male
Female

*Address

*City

*State

*Zip

*Primary Phone Number

Additional phone number (if applicable)

*Preferred Time

*Preferred Date

*Enter Code Displayed (Security)

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Health Fair Patient Registration

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