Patients & Visitors
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Please complete the form and indicate your acknowledgement to voluntary release and consent to health screening below.
Voluntary Release and Consent to Health Fair Participation
I acknowledge that I have voluntarily chosen to participate in this health screening or event sponsored by Clark Memorial Health. In connection with my health fair participation, I hereby voluntarily agree to the following: Consent to Health Screening, General Release, Distributed Materials, Responsibility for Further Treatment, and Notice of Privacy Practices.