Vaccine Consent Form

Diabetic A1C Screening Form

***DUE TO SUPPLY SHORTAGES WE ARE CURRENTLY UNABLE TO OFFER A1C TESTING. CHECK BACK!****
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Form completed by?*

First NameLast Name
Primary Care Provider (PCP) Name*

First NameLast Name
PCP Phone Number*

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

YesNO
Do you currently have a fever?*

YesNO
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?*

YesNO
Are you currently waiting on the results of a COVID-19 test?*

YesNO
Are you diabetic?*

YesNO
If yes, do you have type I or type II diabetes?

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

YesNO
Please list all current medications.
When was your last A1C screening?
Are you pregnant?*

YesNO
Do you have any medication allergies?*

YesNO
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!

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

prevnext( X )
USDDescription
Should be Empty:

Diabetic A1C Screening Form

Consent