Name First Name Last Name Address Address City/Town ZIP/Postal Code State - Select -IllinoisIowaMissouri Phone Number Email Address Date Of Birth Age For Blessing Health Employees Only: Please List Your Closest Location - Blessing Hospital, Illini Community Hospital, Blessing Health Hannibal Health History Questions Do you have a known history of colon cancer? Yes No Unsure Have you previously performed a stool for blood test (hemoccult or FIT)? Yes No Unsure Have you had a colonoscopy within the past: 1-5 years 5-10 years 10 years or more Never Consent For Screening I understand this screening is ONLY for the limited purpose of detecting fecal immunochemical. It is NOT a complete medical examination. No other diagnosis of symptoms, diseases, defects or conditions will be made. No treatment will be provided to me at this screening. I know to contact my physician if this limited fecal immunochemical screening requires further evaluation or if I have any questions or concerns. I consent to my results being used for statistical purposes provided my identity is not disclosed. I consent to my fecal immunochemical screening results being reviewed for quality assurance by a physician of the Cancer Committee. I, and on behalf of my heirs, beneficiaries and personal representatives, release and hold harmless Blessing Hospital, Blessing Corporate Services, Blessing Physician Services, and their employees, representatives and agents from any and all claims of liability associated with my participation in the Fecal Immunochemical Screening, including but not limited to, any accidents, injuries, illnesses or other damages, risks or losses of any kind, whether foreseen or unforeseen, known or unknown, which may arise. I consent to the Fecal Immunochemical Screening. Yes No I consent to the release of my Fecal Immunochemical Screening results to me. Yes No I consent to the release of my Fecal Immunochemical Screening Results to my Primary Care Provider. Yes No Primary Care Provider Name (If You Not Have One, Enter N/A) I have read, or had read to me, this consent form, and I understand and agree to its contents. Yes No Participant Signature Reset Sign above May we contact you about future screening events? Yes No Submit Leave this field blank
