Legal Blood Sample Form

LEGAL BLOOD SAMPLE FORM

This Legal Blood Sample Form is made and entered into by and between Requesting Party Name: and Donor Name: . Effective Date: . Location of Collection:

RECITALS

WHEREAS, Requesting Party requires a blood specimen from Donor for lawful purposes including but not limited to evidentiary testing, chain-of-custody preservation, laboratory analysis, or presentation in judicial or administrative proceedings; and

WHEREAS, Donor is willing to provide a blood specimen under the terms and conditions set forth herein, including authorization for collection, testing, retention, and disclosure as required for legal proceedings; and

WHEREAS, the parties desire to establish an unambiguous chain of custody, designate authorized recipients, and allocate responsibility for storage, testing, and cost of analysis.

NOW THEREFORE

In consideration of the mutual covenants contained herein, and other good and valuable consideration, the parties agree as follows:

1. DEFINITIONS

For purposes of this Agreement, "Specimen" means the blood sample collected from Donor; "Chain of Custody" means the documented record tracking physical possession, transfer, and storage of the Specimen from collection until final disposition; "Authorized Recipients" means those persons or entities designated in Section 6.

2. AUTHORIZATION FOR COLLECTION

Donor hereby authorizes a qualified medical professional or trained phlebotomist to collect a blood Specimen for the purposes described herein. Donor consents to venipuncture or capillary collection as appropriate and acknowledges that minor discomfort or bruising may occur.

3. SPECIMEN DETAILS

Specimen Type: Venous Blood Capillary Blood Other:

4. COLLECTION SITE AND COLLECTOR

5. PURPOSE AND AUTHORIZED USE

Purpose (select all that apply): Paternity/Parentage Criminal Legal Proceeding Civil/Administrative Proceeding Insurance/Employment Other

6. CHAIN OF CUSTODY AND TRANSFER

The parties agree to maintain an unbroken Chain of Custody. Each transfer of the Specimen must be recorded with name, organization, date, time, and purpose. The initial recording shall be completed by the Collector at the time of collection.

7. TESTING, RESULTS, AND RELEASE

Donor authorizes testing of the Specimen by authorized laboratories for analyses reasonably related to the stated Purpose. Results, chain-of-custody records, and supporting documentation may be released to Authorized Recipients, subject to applicable confidentiality limitations set forth below.

8. CONFIDENTIALITY; PRIVACY

Records and test results shall be treated as confidential and released only in accordance with this Form or as required by lawful process. Requesting Party shall take commercially reasonable measures to safeguard personal health information and genetic data and shall limit disclosure to Authorized Recipients and legal counsel when necessary for the Purpose.

9. LIABILITY AND INDEMNIFICATION

Requesting Party shall be responsible for costs associated with collection, testing, storage, and transfer of the Specimen unless otherwise agreed in writing. Requesting Party agrees to indemnify, defend, and hold harmless Donor from third-party claims arising from authorized testing and disclosure under this Form, except to the extent caused by Donor's gross negligence or willful misconduct.

10. RETENTION AND DISPOSITION

Unless otherwise directed in writing, Specimen retention will comply with applicable institutional policies. After the retention period, the Specimen will be securely destroyed. Requests for extended retention must be made in writing and require mutual written consent.

11. NOTICES

All notices required or permitted under this Form shall be in writing and delivered to the addresses provided below or such other address as either party shall designate in writing.

12. AMENDMENTS; WAIVER; ENTIRE AGREEMENT

This Form may be amended only by a written instrument signed by both parties. No waiver of any provision shall be effective unless in writing. This Form constitutes the entire agreement between the parties with respect to the collection, testing, retention, and release of the Specimen and supersedes all prior agreements and understandings.

13. SEVERABILITY; GOVERNING LAW

If any provision of this Form is held invalid or unenforceable, the remainder of this Form shall remain in full force and effect. This Form shall be governed by and construed in accordance with the substantive laws of the jurisdiction in which collection occurs, without regard to choice-of-law rules.

14. WITHDRAWAL OF CONSENT

Donor may withdraw consent in writing at any time prior to collection. Withdrawal after collection will not affect testing or disclosure already performed in reliance on this Form, and will not require destruction of samples or results already produced.

15. ACKNOWLEDGMENTS AND CERTIFICATIONS

By signing below, Donor certifies that Donor has read and understands the contents of this Form, has had the opportunity to ask questions, and voluntarily consents to the collection and use of the Specimen for the purposes stated. Requesting Party certifies that it will comply with the terms of this Form and maintain accurate chain-of-custody records.

16. ATTACHMENTS

The following documents, if completed and attached, are incorporated into this Form: chain-of-custody log, laboratory testing authorization, and any written directives regarding retention or secondary use.

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