First Name

Last Name

Birth Date

Month

Day

Year

Sex at Birth:

Male
Female

Phone Number

Preferred Language:

English
Spanish
Other

Which option correctly describes your health insurance plan?

We ask for health insurance information to help determine eligibility for screenings.

Commercial
Medicare
Medicare Advantage
Medicaid
No Insurance

Screening Eligibility Questionnaire

Please answer the questions below and check all screenings/labs you would like to request.

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Prostate Cancer Screening (Blood Draw)

Eligibility: Men age 45 or older who have never been screened or were last screened over one year ago. Those who have a family history of prostate cancer or are African American may qualify for a screening at age 40.

I am male and age 45 or older and would like to receive prostate cancer screening.
I am male, age 40 or older, that has family history of prostate cancer / identifies as African American.

When was your last prostate cancer screening?

Never
Over 1 year ago
Within the last year

Lung Cancer Screening (Imaging)

Eligibility: Adults ages 50-80 with a 20 or more pack-year smoking history.

I am between 50 and 80 years old.
I would like to receive a lung cancer screening.

Do you have a 20 pack-year smoking history?

Example: 1 pack/day for 20 years or equivalent.

Yes
No
Not Sure

If you are interested in having a Skin Cancer Screening, please mark the reason why below.

Personal history of prior skin cancer, precancerous lesions or biopsies
Frequent Sunburns in lifetime
Tanning Bed Use
Immunosuppressed (Medications, organ transplant, HIV status)
Skin Cancer in first degree relative (parent, sibling, children)

Cash Lab Options

Please check each Cash Lab you would like to have drawn.

The Wellness Panel includes CBC, CMP, and Lipid Panel.

Wellness Panel $60
Hemoglobin A1C $20
PSA (Prostate) $40
TSH Free T4 $30
Vitamin D 25-OH $40

Adult Immunization Options

What Adult Immunizations are you interested in?

Influenza
Pneumonia
Shingles

Acknowledgement & Consent

I confirm that the information I provided is accurate to the best of my knowledge.
I understand that eligibility will be verified and services are subject to availability.
I understand that protected health information (PHI) will be collected and used solely for the purpose of provided health services, care coordination, and follow-up, in accordance with HIPAA regulations.
I understand that photographs and/or video recordings may be taken during the event for educational, outreach, or promotional purposes.
I understand that participation in photography or video is voluntary and will not affect my ability to receive services.

Photography Consent:

I consent to photography/video.
I do not consent to photography/video.

Participant ESignature

Date

Health Fair Preregistration Form

Health Fair Preregistration

Screening Eligibility Questionnaire

Cash Lab Options

Adult Immunization Options

Acknowledgement & Consent