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New Jersey Lord Sri Venkateswara Swami Health Camp

With the blessings of Lord Sri Venkateswara, HTCS in collaboration with Indian Health Camp of New Jersey
(IHCNJ) is organizing a Health Screening and Disease Prevention Fair for the people over age of 40 without
medical insurance.
Date: Sunday, June 4th, 2017 Time: 8:30 AM – 1:00 PM Place: HTCS Community Center
Screening includes:
Basic blood test, Electrocardiogram (EKG), Eye examination, Physical examination, Dental screening, Physical therapy, Cancer screening/prevention & education, Cardiac evaluation/counseling, Pharmacy & dietary counseling and other Ancillary services.

Sri Venkateswara Temple and Community Center
Note: 12 hours FASTING is required for blood test.
Breakfast will be provided after the blood test is completed.
Continue all medications the day before and the day of the blood test.
Bring all your medications with you to the health camp.

The application (one per person) along with the camp refundable fee of $10 (Payable to HTCS) may be handed in person at the temple office or mailed to temple office at One Balaji Tempe Drive, Bridewater, NJ 08807 (must receive before May 24th, 2017). The application form can also be mailed to IHCNJ, P.O. Box 5686, Hillsborough, NJ 08844 with a refundable deposit check of $10.00 per applicant payable to IHCNJ.
Screening will be provided to the pre-registered applicants ONLY.
Please note that the $10 deposit will be refunded ONLY if the applicant is present on the day of the camp.

Section 1: Patient Information (USE CAPITAL LETTERS ONLY)
LAST NAME:____________________________FIRST _____________________________ MIDDLE_________________
Address: _____________________________________________ E-mail:________________________________________
City: __________________________________State: ______ Zip Code:___________ Home Phone: __________________
Date of Birth: _____(mm/dd/yyyy)_________ Age: _______ Male ___Female: ___ SSN: ___________________

Section 2: Applicant’s Signature is required
I understand that this health fair is for screening and counseling only. HTCS and IHCNJ will not be responsible
for any treatment. I also understand that HTCS, IHCNJ, laboratory, participating health care professionals
and volunteers have NO LIABILITY for any damage nor any of them responsible for any malpractice claim for
this particular event. In addition, I understand that the HTCS is only providing breakfast and the temple
facility for the health camp screening for this day and is not in any way affiliated with IHCNJ.

Signature: _____________________________________ Date: _______________________

For further information:
Mrs. Bala Yalamanchi: 908-884-5722 Shirish Parekh: 908-468-7829
Community.affairs@venkateswaratemple.org Dr. Tushar Patel: 848-391-0499

Hindu Temple and Cultural Society of USA, Inc. (HTCS)
Sri Venkateswara Temple (Balaji Mandir) and Community Center
One Balaji Temple Drive
Bridgewater, NJ 08807, USA
Telephone 908-725-4477

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