Consent Form

Consumer-Friendly Testing Consent

Please complete this form before your consumer-friendly lab testing appointment. No doctor's order required. Testing is performed by a certified laboratory.

Consumer-Friendly Testing: These tests are self-ordered — no doctor's order required. Results will be released directly to you. A mobile fee may apply. Testing is performed by a certified laboratory. ID is required at the time of service.

Patient Information

First Name*

Last Name*

Date of Birth*

Phone Number*

Email Address

Address

City*

State*

ZIP Code

Testing Details

Tests Requested *

Preferred Collection Date

Preferred Collection Time

Consent & Policies

I voluntarily consent to specimen collection by Blessed Hands Mobile Phlebotomy Services, LLC for consumer-friendly (direct-to-consumer) laboratory testing.

I understand that no doctor's order is required for consumer-friendly testing and that results will be released directly to me.

I understand that Blessed Hands Mobile Phlebotomy Services, LLC (BHMPS) provides specimen collection services only and does not diagnose, treat, or provide medical advice. BHMPS is not responsible for test results.

I understand that a mobile fee may apply in addition to laboratory fees, and that all fees will be disclosed prior to scheduling.

I acknowledge that government-issued ID is required at the time of service.

I understand that submitting this form does not guarantee an appointment — my appointment is confirmed only upon receiving a confirmation call or email.

I agree to provide a safe, clean, and adequately lit environment for the phlebotomist to perform the collection.

I agree to seek medical advice, care, and treatment from my healthcare provider regarding any questions, concerns, test results, symptoms, or medical conditions. If I become ill or experience symptoms, I will contact my healthcare provider or seek appropriate medical attention.

I agree to assume full financial responsibility for all laboratory tests and services requested. I understand that payment for testing and specimen collection services is due prior to specimen collection and that services will not be performed until payment has been received. No insurance billing is provided unless otherwise specified.

Prices are subject to change without notice. Prices include travel fee.

Adult Patient Signature

Complete this section if the patient is 18 years of age or older.

Signature (Type Full Name)

Printed Name

Date

Minor / Guardian Consent

Complete this section if the patient is under 18 years of age.

Guardian Signature (Type Full Name)

Guardian Printed Name

Relationship to Patient

Date

Minor Signature / Assent (if applicable)

Minor Assent Date

Staff Use Only

Staff Name

Credentials

Staff Signature

Date