Vaccine Consent Form

Diabetic A1C Screening Form
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Form completed by? *

First Name Last Name
Primary Care Provider (PCP) Name *

First Name Last Name
PCP Phone Number *

Area Code Phone Number
Name of pharmacy *
Pharmacy phone number *
Are you Currently Sick? *

Yes NO
Do you currently have a fever? *

Yes NO
Do you have any reason to believe you are infected with COVID-19 or have been in contact with someone with COVID-19 within the last 14 days? *

Yes NO
Are you currently waiting on the results of a COVID-19 test? *

Yes NO
Are you diabetic? *

Yes NO
If yes, do you have type I or type II diabetes?

TYPE 1 TYPE 2
Please list your other disease states such as high cholesterol, hypertension, etc.
Are you currently taking any diabetic lowering medication? *

Yes NO
Please list all current medications.
When was your last A1C screening?
Are you pregnant? *

Yes NO
Do you have any medication allergies? *

Yes NO
Explain "Yes" response above.
Consent

I have had the opportunity to ask questions about this test. I believe the benefits outweigh the risks and I voluntarily assume full responsibility for any reactions that may result from either my receipt of this screening or the receipt of the screening by the person named above for whom I am the legal guardian ("Ward"). Please sign below to indicate consent to screening.
Signature *

Clear
A1C Appointment
Thank you for trusting Altitude Drug with your healthcare needs! We are currently booking for our special "10th birthday celebration" healthfair taking place on May 6th. Take advantage of this customer appreciation, birthday rate!

Check back after May 6th, if you need to schedule for an alternative date. (Please note, the regular price for A1C testing is $25.)

Please show up to appointments on time.

No refunds will be given for missed appointments.

Fees are non-refundable and non-transferable.

Give us a call at 367.2278 with any questions.
Diabetic A1C

prev next ( X )
USD Description
Should be Empty:

Diabetic A1C Screening Form

Consent