Screening Participant Intake Form

  • Contact Information (13 questions):

  • Participant Demographics:

  • 13. Screening Consent and Release Form

  • You are participating in a free, voluntary kidney disease awareness screening provided by the Tennessee Kidney Foundation. The purpose of this screening is to find out if you are at increased risk for kidney disease or if you are showing signs and symptoms of kidney disease. This program is for informational and educational purposes and it is not a diagnosis or a medical treatment. This screening is not a substitute for consulting your health care professional.

  • Participants must be 18 years or older and sign this release form giving Tennessee Kidney Foundation permission to perform the screening test. Participants13-17 may be screened with a parent or guardian present. You may withdraw from the screening process at any time. All information about you, your answers to questions and your results are confidential. To protect your privacy, you will be assigned a Participant ID number. This number will be used to identify you whenever possible. Your name, your participant ID and the results relating to you may be provided to researchers or safety and privacy review boards.

  • By checking the box for consent below, I voluntarily agree to participate in this screening, and I give permission for the screening to be performed. I also agree that I will not hold Tennessee Kidney Foundation, its officers, directors, employees, or volunteers liable for any demands, claims, and/or judgments that might arise as a result of my participation here today.

  • MM slash DD slash YYYY