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Blood Pressure Screening Consent Form To be completed by participant Participant Name Gender Male Female Date of Birth // Company Name Location I hereby consent to blood pressure screening services. I understand that these services are being offered as part of an educational awareness program and results will be provided to my employer in aggregate format only. Signature of Participant Date BP Reading / Please check the most appropriate category based on screening result Ideal 120/80 Moderate Risk 120-139 / 80-89 High Risk 140-159 / 90-99 Extreme 160/100 I hereby confirm the above test results are considered accurate. I understand that these services are being offered as part of an educational awareness program and results will be provided to my employer in aggregate format only. Signature of Participant Date BP Reading / Please check the most appropriate category based on screening result Ideal 120/80 Moderate Risk 120-139 / 80-89 High Risk 140-159 / 90-99 Extreme 160/100 I hereby confirm the above test results are considered accurate. .

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