Patient Intake

Patient Forms

Complete all required forms in one place. Your information is shared across sections so you only need to enter it once.

Blessed Hands Mobile Phlebotomy Services

Step 1 of 5

Phlebotomy Consent

Patient Information

First Name*

Last Name*

Date of Birth*

Medical Record / ID #

Phone*

Address *

City*

State*

ZIP Code

Facility / Procedure Information

Facility / Clinic

Ordering Provider*

Type of Collection *

Reason for Collection *

Mobile Draw PolicyA $25 trip fee may apply for missed or cancelled appointments with less than 24 hours notice. The patient must provide a safe, clean, and adequately lit environment. Results will be released to the ordering provider unless patient-initiated testing. Travel fees may apply based on distance.

Informed Consent StatementI understand that phlebotomy is the collection of a blood sample by needle stick or finger stick. Common risks may include temporary pain, bruising, bleeding, lightheadedness, and rarely infection. I may ask questions before the procedure and may refuse or stop at any time.

Adult Patient Consent

I am the patient named above and voluntarily consent to the blood collection procedure described.

Adult Patient Signature

Date

Time

Printed Name

Minor / Guardian Consent

Complete if signing on behalf of a minor patient.

Parent/Legal Guardian Signature

Date

Time

Printed Name

Relationship to Minor

Optional Minor Assent

Minor Signature

Date

Staff Member Performing Collection

Staff Name

Credentials

Signature

Date

Witness Name / Signature

Witness Date