Blessed Hands Mobile Phlebotomy Services, LLC
Blessed Hands Mobile Phlebotomy Services, LLC
432.701.8903 · [email protected] · bhmps.com
Informed Consent for Phlebotomy Services

Required Before Collection

Informed Consent for Phlebotomy Services

Blessed Hands Mobile Phlebotomy Services, LLC — please read carefully and complete all required fields before your appointment.

Patient Information

Consent for Specimen Collection

I voluntarily consent to specimen collection services provided by Blessed Hands Mobile Phlebotomy Services, LLC. I understand that these services may include venipuncture (blood draw), capillary collection, urine collection, saliva collection, buccal swab collection, and other specimen collection procedures as ordered or requested.

I understand that specimen collection procedures involve certain risks, including but not limited to:

  • Pain or discomfort at the collection site
  • Bruising or hematoma
  • Bleeding
  • Dizziness or fainting
  • Infection at the puncture site
  • Nerve irritation or injury (rare)
  • Unsuccessful specimen collection requiring additional attempts

I acknowledge that no guarantee has been made regarding the success of specimen collection or laboratory testing results.

Important Policies & Disclosures

Medical Disclaimer

I understand that Blessed Hands Mobile Phlebotomy Services, LLC provides specimen collection services only and does not diagnose, treat, interpret laboratory results, prescribe medications, or provide medical advice.

I agree to seek medical advice, care, and treatment from my healthcare provider regarding any questions, concerns, symptoms, test results, or medical conditions.

Financial Responsibility

I agree to assume full financial responsibility for all requested services and laboratory testing fees. I understand that payment is required prior to specimen collection unless other arrangements have been approved.

Additional Fees: Travel outside the standard service area is subject to a mileage fee of $0.75–$1.00 per mile. This fee will be communicated prior to the appointment and is due at the time of service.

Laboratory Fees

Laboratory testing fees are separate from and in addition to the mobile phlebotomy service fee charged by Blessed Hands Mobile Phlebotomy Services, LLC. The phlebotomy service fee covers specimen collection, handling, and transport only.

Third-Party Laboratory Billing

Specimens are sent to an independent, certified third-party laboratory for analysis. All laboratory processing fees are billed directly by that laboratory and are the sole financial responsibility of the patient or ordering provider. Blessed Hands Mobile Phlebotomy Services, LLC is not responsible for laboratory billing, insurance claims, or disputes with the laboratory.

Insurance & Coverage

If you are using insurance for laboratory testing, it is your responsibility to verify coverage, obtain any required authorizations, and ensure the laboratory is in-network with your insurance provider. Blessed Hands Mobile Phlebotomy Services, LLC does not bill insurance on behalf of patients for laboratory fees.

Result Turnaround

Laboratory result turnaround times vary by test type and laboratory. Blessed Hands Mobile Phlebotomy Services, LLC does not control result release timelines and is not responsible for delays caused by the laboratory.

By signing this consent, I acknowledge that I have been informed of the separate laboratory fee structure and accept financial responsibility accordingly.

Confidentiality

I understand that my personal and health information will be maintained in accordance with applicable privacy laws, including HIPAA, and will only be disclosed as permitted by law.

Release of Liability

I authorize Blessed Hands Mobile Phlebotomy Services, LLC and its representatives to perform specimen collection services. I release and hold harmless Blessed Hands Mobile Phlebotomy Services, LLC, its owners, employees, contractors, and representatives from liability arising from ordinary risks associated with specimen collection, except where prohibited by law.

Cancellation and No-Show Policy

To provide timely and efficient service to all clients, we respectfully request advance notice for appointment cancellations or rescheduling.

Cancellations

Appointments canceled at least twenty-four (24) hours before the scheduled appointment time may be rescheduled without penalty.

Appointments canceled less than twenty-four (24) hours before the scheduled appointment may be subject to a cancellation fee.

No-Shows

A "No-Show" occurs when a client fails to be present for a scheduled appointment without prior notification.

Clients who fail to appear for their appointment may be charged a no-show fee and may be required to prepay for future appointments.

Late Arrivals

If a client is unavailable at the scheduled appointment time, Blessed Hands Mobile Phlebotomy Services, LLC will make reasonable efforts to contact the client. If the appointment cannot be completed due to client unavailability, the appointment may be considered a no-show.

Emergencies

We understand that emergencies and unforeseen circumstances occur. Cancellation and no-show fees may be waived at the sole discretion of Blessed Hands Mobile Phlebotomy Services, LLC.

Refunds

Mobile service fees, travel fees, and other applicable charges may be non-refundable once travel to the appointment location has begun.

By scheduling an appointment, the client acknowledges and agrees to this Cancellation and No-Show Policy.


To cancel or reschedule, please contact us:

📞 432.701.8903  |  ✉️ [email protected]

Acknowledgment: I have read and understand this Informed Consent. I have had the opportunity to ask questions and voluntarily consent to receive specimen collection services.

Patient Signature

Complete if patient is 18 years of age or older.

Sign here

Parent / Guardian Signature (if applicable)

Complete if signing on behalf of a minor patient.

Sign here

Phlebotomist Signature

To be completed by the staff member performing the collection.

Sign here