Company Name and Address_____________________________________________________________________

City _____________________________________________ State____________________Zip_________________

Age _____              Sex: Male_____ Female_____

Last time you ate or drank, not including water (only applicable for glucose and triglyceride testing):_____________

Please read and sign:
I hereby consent to the drawing of a blood sample for the purpose of measuring my blood cholesterol level. I hereby release Corporate Health Initiatives, Inc., my employer, the company sponsoring this event, and other companies and organizations associated with this testing, parent and affiliated companies, their agents, representatives, employees, successors, assignees, governing bodies, and advisory committees from any and all liability arising from or in any way connected with blood drawing for blood cholesterol measurement, or from the data derived therefrom. I understand that:

1. The data derived from this test is to be considered preliminary only and does not constitute a diagnosis of any kind.
2. No guarantee of any kind is made to me with respect to this screening.
3. The responsibility for initiating a follow-up examination to confirm high blood cholesterol and obtain advice and professional medical treatment is mine and not that of CHI or any other organization associated with this screening.
4. It is the responsibility of each participant to follow up with their own primary care physician if their test results are in the abnormal range. If a participant does not have a primary care physician, ask the attending CHI nurse to give you an appropriate referral.
5. CHI will keep my results in the strictest of confidence, and may release only aggregate data to my employer or other organizations unless instructed differently, in writing on this form, by me.