Healthcare Phlebotomy Agreement

Healthcare Phlebotomy Agreement

Facility Name:   Facility Address:

Patient Information

Date of Birth:   Gender:

Phone:   Medical Record/Account No.:

Insurance Information

Policy Number:   Group Number:

Medical History / Special Considerations

I have a diagnosed bleeding disorder.    I am currently taking anticoagulant or antiplatelet medication.

Phlebotomy Procedure and Authorization

Procedure: I authorize qualified clinical personnel to perform venipuncture or capillary blood collection for clinical testing, specimen collection, and related procedures. Specimen type: . Number of required tubes/collections: .

Risks and Complications: I understand the common risks include brief pain, bruising, hematoma, bleeding, fainting, infection at the puncture site, and nerve irritation. Rare complications include significant hemorrhage, infection requiring treatment, or injury to surrounding structures. If I have a bleeding disorder or am on blood thinners, risks may be increased.

Attempts and Alternatives: I understand reasonable attempts will be made to obtain a specimen. If venipuncture is unsuccessful, alternative methods such as capillary collection or referral may be used. I acknowledge I may refuse the procedure; refusal may delay diagnosis or treatment.

Specimen Handling, Testing and Release

Authorization to Test and Release Results: I authorize the Facility and its contracted laboratories to collect, process, test, store, and dispose of my specimen. I authorize release of test results and relevant clinical information to the ordering provider and to the persons I identify below. Release to:

Residual Specimens: I consent to storage of residual specimen for quality control or further clinically indicated testing.    I consent to de-identified residual specimen use for future research (optional).

Authorization Expiration: This authorization shall remain in effect until unless earlier revoked in writing. I understand revocation will not affect disclosures or actions already taken in reliance on this authorization.

Privacy Acknowledgment

I acknowledge that I have been informed of the Facility's privacy practices regarding my health information and that test results may be released to authorized providers and designees as necessary for treatment, payment, and healthcare operations.

Patient Representations, Liability and Certification

I represent that the information I have provided is accurate to the best of my knowledge. I understand that failure to disclose relevant medical history (including bleeding disorders or medications) may increase my risk of complications. I consent voluntarily and understand the nature and purpose of the procedure. I release the Facility, its employees, and contracted laboratories from liability for customary complications arising from the procedure, except for acts of gross negligence or willful misconduct.

Questions: I have had the opportunity to ask questions about the procedure, risks, benefits, and alternatives, and those questions have been answered to my satisfaction.

Additional Instructions / Notes

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