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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