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Pay for appointments:
$30.00 per appointment
*No Refund due to expenses are already incurred for this event.

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To sign up for an appointment with Heart Watch 2 mobile laboratory, please fill out the form below. Please be sure to include your Name, E-mail and Phone Number so that we can contact you if necessary.

*No Refund due to expenses are already incurred for this event.
HEALTH SCREENING CONSENT AND RELEASE STATEMENT
CHOLESTEROL / GLUCOSE / HbA1c / HEMOGLOBIN / BONE DENSITY SCREENING / BLOOD TYPING / TSH / hs-CRP / VIT D

I hereby release Alere Corporation, PTS Diagnostics, Heart Watch 2, other organizations associated with this screening, parent and affiliated companies, successors and assigns, and officers, directors and employees from any and all liability arising from or in any way connected with fingerstick blood collection for my blood cholesterol, glucose, HbA1c , hemoglobin, TSH, hs-CRP or Vitamin D measurement ; the ultrasound for my bone density measurement or from the data derived therefrom. I understand that:

1) The data derived from these tests are to be considered preliminary only and do not constitute a diagnosis of
hypercholesteremia or diabetes, anemia or osteoporosis.

2) These tests do not pose any serious health risks. Fingerstick punctures, as with any cut or laceration, could become
infected if proper precautions are not taken. A small percentage of people may feel faint during the procedure.

3) The responsibility for initiating a follow-up examination to confirm high blood cholesterol, high blood sugar, anemia or osteo-
porosis and obtain advice and treatment is mine and not that of my physician or the organizations associated with this screening.

4) Personal data will never be shared with any entity without my express written permission.

Thank you!