Wyoming Health Fairs Consent and Acknowledgement

For the purposes of this document, Wyoming Health Fairs/Wellness Health Fairs (WHF) refers to its employees, staff, volunteers, coordinators, and any contracted personnel including laboratory, transportation, and medical technologists.

Lab results will be forwarded to me or to my representative unless specified that the results are to be released only to me. (Release form available upon request.)

It is my responsibility to forward my lab results to my physician. For other options, WHF can provide a medical release authorization form.

WHF does not practice medicine or recommend medical treatment.

WHF does not interpret lab results for me.

WHF takes precautions in the event contamination occurs during the process of drawing, transporting, and processing blood against the risk of accidental exposure to blood-borne diseases.

Wyoming state law allows any routine testing deemed necessary for the safety of the contaminated individuals to be carried out at no additional expense to me. I consent to such testing.

I realize that my health information will be used for the purposes of treatment, payment, and health care operations, and that my privacy will be protected.

I accept WHF Privacy Practices and can request a copy.

I request and give permission to WHF to draw my blood and perform lab tests on that blood.

I release Wyoming Health Fairs and its employees and agents from liability for any injury which I may incur as a result of my participation in this blood draw, including its or their negligence.

Random photographs and videos may be taken during the event. Your signature indicates you are giving permission to use these forms of media for marketing purposes, i.e., WHF website.

I, the undersigned, agree to pay for all services rendered to me immediately upon demand. I further agree that in the event of non-payment of any amounts due under this agreement, I will pay interest thereon at the rate of 1.75% per month, and pay all reasonable attorney fees and court costs should suit be instituted. I also agree that in the event this agreement is assigned to an agency for collection, I promise to pay an additional fee of 35% of the unpaid balance due.

Updated Date: 4/11/25