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(Sponsored by the Port Allegany Rotary Club & CCMH)

APPOINTMENT NECESSARY
Use the online form or Call Charles Cole Memorial Hospital Centralized Scheduling,
9 a.m. - 5 p.m., Monday - Thursday 274-8200

Comprehensive Blood Analysis - $45

Screening for over 30 commonly requested blood tests including CBC and comprehensive, coronary risk, and liver function profiles.(a 12-hour fast is recommended. Refrain from consuming all food and beverages. You may have water and you should continue to take all medications prescribed by your doctor.) 

Optional Tests:

Prostate Specific Antigen (PSA) - $25
Thyroid Stimulating Hormone (TSH) - $15

By voluntarily participating in the Comprehensive Blood Analysis Screening, I recognize and accept all associated risks. I understand that the program is only a screening and does not constitute a complete medical exam or diagnosis. For diagnosis of a medical problem, participants must see a medical provider for a complete medical exam. All participants must be 18 years of age or older.

Cash and Checks Only
Checks can be made payable to Port Allegany Rotary

All Fields Required

Last Name
First Name
Middle Initial
Email

Date of Birth (mm/dd/yy)

Yes No - Comprehensive Blood Analysis
Yes No - PSA (Prostate Specific Antigen)
Yes No - TSH (Thyroid Stimulating Horomone)

Daytime Phone #
Evening Phone #
Address
City, State, Zip
Medical Provider Name

**If your medical provider is not affiliated with Charles Cole, please provide complete contact information in the "comments" section below including provider name, address and telephone**

Comment/Question **Medical provider contact information**

When was the last time you saw the physician? Enter year here:

Preferred appointment time: 8:45 am 9:15 am 9:30 am 9:45 am
(if a specific time does not appear in the drop-down box it indicates that there are no more appointments available for that time.)

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