Healthcare PT INR Form

HEALTHCARE PT / INR LAB AND CONSENT FORM

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance / Billing

Policy/ID No.:    Group No.:

Ordering Clinician / Encounter

Clinic / Location:    Phone:

Anticoagulation / Medication History

Current anticoagulant medication(s):

Date/time of last dose:    Missed doses in past 7 days:

Indication for PT/INR Testing

Indication (check applicable): Atrial fibrillation DVT/PE Mechanical heart valve Other:

Specimen / Lab Result

Date/time of specimen:    Specimen source:

PT (seconds):    INR:    Laboratory reference range / comments:

Clinical Assessment & Safety

Signs or symptoms of bleeding (describe):

Recent thrombotic events (past 30 days):

Result Interpretation and Orders

Target INR range:    Clinician interpretation:

Recheck INR (date or interval):    Additional orders:

Consent, Authorization, and Patient Acknowledgment

I authorize collection of blood for PT/INR testing and related laboratory analysis. I understand the purpose of the test is to monitor anticoagulant therapy and guide dose adjustments. I acknowledge that risks of specimen collection include minor pain, bruising, or bleeding and that, rarely, more serious complications may occur. I have had the opportunity to ask questions and those questions have been answered to my satisfaction.

I authorize release of my PT/INR results and related clinical interpretations to the ordering clinician and other treating providers involved in my care. I understand I may withdraw this authorization in writing at any time except to the extent that action has already been taken in reliance on this authorization. This authorization will expire on the date I specify below or one year from the date of signature if no expiration date is provided.

Authorization expiration date:

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