Phone: (402) 684-3366Fax:(402) 684-3677
102 East South StreetBassett, NE 68714
E-mail: rchospital@rockcountyhospital.com
The first Wednesday of every month 7:30am-4:30pmA Legacy of Caring • 102 E. South Street, Bassett, NE 68704 • Phone: 402-684-3366 • Fax: 402-684-2612
* Only for notification of abnormal results that need immediate attention. Otherwise, it is MY responsibility to give this information to my healthcare provider.
I understand these results will become a part of my medical record. I also understand that if I do not have a provider, results that need immediate attention will be forwarded to the Rock County Medical Director or Rock County Clinic provider. Any and all laboratory results reported at this time are my responsibility to forward on to my healthcare provider. I understand that it is my responsibility to follow up this testing with my healthcare provider at which time any questions I have about my laboratory results will be addressed.
The undersigned has been informed of the diagnostic laboratory examination to be performed and certifies that no guarantee or assurance has been made regarding the exam.
It is recommended that participants should be fasting 8-10 hours before the blood collection for the **tests. It is OK to drink water.
I understand I am financially responsible for all charges incurred at Rock County Hospital for this healthfair laboratory testing. Payment is due upon day of testing.
By my Signature, I consent to this testing:
