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This Health Fair is being offered by Shree Jalaram Mandir as a community service to itsmembers free of charge or at no cost basis.In exchange for the services received and other good and valuable consideration received, Ihereby release Shree Jalaram Mandir, its Trustees, Directors, officers, employees and agents andall Shree Jalaram Mandir’s Sponsors and Donor Providers including without limitation allphysicians, nurses, technicians, laboratories, pharmacists and their affiliates, employees andagents and assigns from any and all responsibility, liability and/or obligation regarding thisscreening including any matter or thing committed or omitted which may arise during blooddrawing or other examinations/tests or from the data derived there from or fromrecommendations or follow-up care suggested.I further understand and agree that:1. This is a health screening and does not constitute a complete diagnosticExamination.2. The data derived from such examinations/tests is to be considered as preliminaryand in no way conclusive.3. The results of my examinations/tests will be made available to me by Health Fairvolunteers of Shree Jalaram Mandir and will be treated as privileged and confidentialand will not be released to any one other than my physician upon request.4. The findings will be reported to me with recommendations for follow-up care, andthat I am responsible for following those recommendations and for any relatedexpenses. The responsibility for securing follow-up diagnosis and/or treatment ofany abnormalities identified or lack thereof lies with me as the person responsible forMy own health and not of Shree Jalaram Mandir, its Sponsors and Donor ProvidersI HAVE READ AND UNDERSTAND AND AGREE WITH THE ABOVE PARAGRAPHS.Participant's signature___________________________________ *
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