Wave of Health Consent Form

I, the undersigned, hereby consent to allow me and my family to participate in the Wave of Health program provided by Darsalud Care. I know that this health screening does not start a patient/medical provider relationship. I understand that we will receive screenings that include BMI (Body Mass Index), Blood Pressure, Capillary Blood Glucose and A1c assessments and that all results will be stored and used to evaluate the risk of Diabetes and Heart related conditions.

 

I understand that we will be working together with DarSalud, LifeDOC, University of Tennessee College of Nursing, University of Tennessee Extension, Mid-South Food bank, and other Wave of Health partners in this process.

 

I understand that food, screening, and education are being provided at NO COST TO ME or my family. The nature of this program has been explained and I was able to ask questions.

 

I consent that DarSalud can reach me on my contact information provided below to follow-up and/or get any additional information required.

 

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An Authorized representative for the family should include the names of the individuals from each household participating, provide the best contact information, and sign below.

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© 2017 by DarSalud Management 

1068 Cresthaven Rd #300, Memphis, TN 38119

6063 Mount Moriah Road Ext #4, Memphis, TN 38115