Healthcare Hair Release

HEALTHCARE HAIR RELEASE

Patient Information

Date of Birth:    Gender:

Insurance Information

Medical History

Description of Hair Collection and Intended Use

I authorize the collection of hair and associated material (hair shafts, roots, trimming) by the healthcare provider. Collection may include cutting, trimming, or detaching small samples from scalp, body, or facial hair. Collection specifics (approximate amount/length):

Intended uses (check all that apply):

Diagnostic testing (including toxicology or biochemical analysis)
Long-term storage for future testing or verification
Cosmetic use including wig or prosthetic manufacture
Research or method development (de-identified unless specified)
Forensic analysis or legal chain-of-custody transfer
Disposal after testing / use

Risks, Benefits, and Alternatives

Risks: Minor pain, bleeding, infection at collection site, scarring, cosmetic alteration of hair appearance, and potential disclosure of genetic or biologic information. Benefits: enables diagnostic evaluation, creation of prosthetics, donation to hair-use programs, or contribution to research. Alternatives: declining collection or providing an alternate specimen type where clinically appropriate.

By signing, I acknowledge that I have been informed of the risks and benefits, have had the opportunity to ask questions, and understand that I may refuse or withdraw this authorization as outlined below.

Right to Withdraw and Revocation

I understand that I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on it. To withdraw this authorization provide written notice to the custodian identified below.

Authorization, Ownership, and Release

I hereby authorize the collection, testing, storage, transfer, and disposition of my hair and related biological material for the purposes indicated above. I understand that following collection the specimen may be stored, transferred to third parties (including laboratories, manufacturers, or investigators), or disposed of in accordance with the facility's policies. I release and hold harmless the collecting facility, its staff, agents, and any recipient organizations from liability associated with the authorized uses of the specimen except for willful misconduct or gross negligence.

Ownership and compensation: Unless otherwise agreed in writing, I acknowledge that I will not receive payment for the specimen and that ownership may be transferred to third parties for the authorized uses. If compensation or specific proprietary rights are agreed, such terms must be documented separately.

Privacy and Use of Identifiable Information

I authorize release of relevant health information and identifiers to the parties receiving the specimen for the purposes described. Identifiable information will be handled in accordance with applicable privacy standards. I understand that de-identified specimens and data may be used or shared without further authorization.

I acknowledge receipt of the facility privacy practices related to the use and disclosure of health information as it pertains to this authorization and understand my rights regarding this information.

Acknowledgment and Certification

By signing below I certify that I am the patient or the authorized representative of the patient, that I have the authority to authorize this release, that the information provided on this form is true and correct, and that I understand the contents of this authorization. I understand that signing this form is voluntary and that refusal to sign will not affect my right to obtain treatment, enrollment, or eligibility for benefits unless allowed by law.

I further certify that any questions I had about the collection, use, storage, or transfer of my specimen have been answered to my satisfaction.

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