Community Health Screening Consent Form

Community Health Screening Consent Form — Form Fields

This nonprofit template includes 9 fields. Collect participant consent and basic health information before a free community health screening event. Free to customize and use on ZenBuild.

• Participant Full Name (text, required)
• Email Address (email, optional)
• Phone Number (text, optional)
• Date of Birth (text, required)
• Primary Language (dropdown selection, optional) — options: English, Spanish, French, Arabic, Mandarin, Vietnamese, Somali, Other
• Screenings You Wish to Receive (checkboxes, required) — options: Blood pressure, Blood glucose, Cholesterol, BMI/weight, Vision, Dental check, Mental health screening
• Do you currently have a primary care provider? (multiple choice, required) — options: Yes, No
• I consent to the following (checkboxes, required) — options: Voluntary participation, Use of anonymized data for reporting, Contact for follow-up resources
• Health Conditions or Medications to Note (long text, optional)