Introduction

Thank you for considering participation in our Free Wellness Screening program. This screening is sponsored by Cone Health as part of their commitment to public health promotion and improving health outcomes in the community. It is being offered through your local pharmacy using the SiteLabs online platform.  

Before participating, it is essential that you understand the purpose of the screening and how your personal health information (PHI) will be used. Please read this consent form carefully.

Purpose of the Screening

The Free Wellness Screening, including various health checks (e.g., A1c screening, cholesterol, blood pressure measurement, etc), is a proactive health initiative sponsored by Cone Health. The purpose of these screenings is to:

• Increase access to preventative screenings through local pharmacies in your community.
• Enhance public health awareness and prevention.
• Help individuals identify potential health issues early, leading to better health outcomes.
• Support community members in managing their health proactively.
  

Use of Personal Health Information and Test Results

By participating in this screening, you consent to the following:

Collection and Use of PHI: Your PHI, including your name, date of birth, contact details, and health-related information from the screening, will be collected.  

Sharing of Information with Cone Health: With your consent, your PHI and test results will be shared with Cone Health, who is sponsoring this screening. 

Purpose of Sharing Information:

The information is shared to:

• Assist Cone Health in analyzing community health needs and improving service quality.
• Contact you regarding relevant health-releated products or services provided by Cone Health.
• Enhance Cone Health’s efforts in public health research and improving quality of services.

Confidentiality and Security

We are committed to maintaining the confidentiality and security of your health information. All information shared with Cone Health will be handled in compliance with applicable privacy laws and regulations, including HIPAA.

Voluntary Participation and Right to Withdraw Consent

Your participation in this screening is entirely voluntary. You have the right to withdraw your consent at any time without affecting your future medical care or treatment.  Any changes to your consent must be submitted in writing to: [email protected]  

Questions

If you have any questions about the screening, Cone Health’s role, or how your information will be used, please feel free to ask the Health Professional at the screening site before signing this consent form or email SiteLabs at [email protected]

Consent

By clicking on one of the options below, you acknowledge that you have read and understood this consent form, and agree to the collection, use, and sharing of your PHI and test results as described above.

I agree that any PHI collected during this Free Wellness Screening may be shared with Cone Health.

I do not want any PHI collected during this Free Wellness Screening shared with Cone Health unless I choose a Cone Health provider for follow up.