Blood Draw Informed Consent Form

Your safety is important to us. Please complete the form below to provide your information and confirm your consent for a phlebotomy blood draw appointment. Prestige Mobile Phlebotomy Services LLC. provides specimen collection only and does not diagnosis or treat. Submitting this form confirms your consent to proceed.

First name

Last name

Phone

Date of birth

Month

Day

Year

Purpose of Blood Draw: I understand that a blood sample is being collected for the purpose of laboratory testing, health screening, or diagnostic evaluation as requested by myself or my healthcare provider.

Risks and Discomfort: I acknowledge that the blood draw procedure may involve the following risks: Mild discomfort, bruising, or bleeding at the puncture site. Dizziness, lightheadedness, or fainting. Rarely, infection or hematoma (a collection of blood under the skin)

Medical History: To ensure my safety during the procedure, I confirm the following:

Have you ever fainted during or after a blood draw?

Yes

Do you have a history of of difficult veins or require special accommodations?

Yes

Are you currently taking blood thinners or anticoagulants?

Yes

Consent and Authorization: By signing below I acknowledge that:

I have been informed of the purpose and risks of the blood draw.

I have had the opportunity to ask questions and all my questions have been answered.

I voluntarily consent to the collection of my blood sample by Prestige Mobile Phlebotomy Services LLC

I understand that my results will only be shared with me unless I provide separate written authorization

I understand that Prestige Mobile Phlebotomy Services will maintain confidentiality in accordance with HIPPA and applicable privacy laws

Initials

I declare that the info I’ve provided is accurate and complete.