Healthcare Asbestos Air Quality Test

Healthcare Asbestos Air Quality Test

Patient / Client Information

Date of Birth:    Gender: Male Female Other

Relationship:    Phone:

Insurance Information

Medical and Exposure History

Chronic Conditions (select all that apply): Asthma COPD Heart Disease Other

Smoking Status: Current Smoker Former Smoker Never Smoked

Site & Sample Information

Sample Types Requested: Phase Contrast Microscopy (PCM) Transmission Electron Microscopy (TEM) Clearance Air Sampling Personal Breathing Zone Bulk Material Sampling

Sampling / Chain of Custody

Laboratory Analysis Requested

Authorization, Consent, and Legal Notices

Client Name:

I hereby authorize the collection of airborne asbestos samples and related testing as described in this form. I understand that sampling and analysis will be performed using recognized laboratory and field methods, including but not limited to visual inspection, phase contrast microscopy and/or transmission electron microscopy as appropriate for the requested analysis. I acknowledge that sampling can disturb materials and may temporarily displace dust or fibers; however, the sampler will employ established containment and safety practices to minimize disturbance.

I understand that analysis results represent conditions at the sampled location and time and that negative results do not guarantee absence of asbestos in other areas. Results are provided for informational and health-protective purposes; interpretation for medical diagnosis or treatment requires consultation with a licensed healthcare provider. I release the sampling company and laboratory from liability for consequential damages arising from reliance on sampling results beyond their intended scope of environmental assessment, except for gross negligence or willful misconduct.

I agree to pay applicable fees for sampling, analysis, and associated services. Estimated fees will be provided separately. Requests for expedited analysis may incur additional charges. I understand samples and associated records may be retained by the laboratory for required retention periods and that disposal of residual samples will be conducted in accordance with standard laboratory procedures.

I acknowledge receipt of the facility privacy notice concerning protected health information and authorize release of test results to the following individual(s) or entities as necessary for care, remediation, or billing purposes:

Authorization Expiration Date:

I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance upon it. Any revocation will not affect disclosures made prior to receipt of the revocation.

HIPAA / Privacy Acknowledgment: I acknowledge that the facility has provided general privacy practices regarding protected health information and that testing results will be handled consistent with those privacy practices.

I acknowledge and consent to release and use of my information as described above.

Laboratory Use and Results

Laboratory results, chain of custody verification, and analyst comments shall be recorded below by authorized laboratory personnel.

Laboratory Accreditation / Method Notes:

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