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APPOINTMENT NECESSARY
Use the online form or Call Charles Cole Memorial Hospital Centralized Scheduling, 
2 p.m. - 5 p.m., Monday - Thursday 260-5474 or toll free 877/364-7905.

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 the Smethport Rotary Club

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 Specific Antigen)

Daytime Phone #
Evening Phone #
Address
City, State, Zip
Family Doctor Name
Family Doctor Town

Preferred appointment time: 7:00 am7:15 am7:30 am7:45 am8:00 am8:15 am8:30 am8:45 am9:00 am9:15 am9:30 am9:45 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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