TWLD Blood Draw ConsentPlease enable JavaScript in your browser to complete this form.Patient Name *FirstLastDate of Birth *Email *Phone *Blood Draw Consent: *I Consent to have blood drawn by Ohio state licensed RN / phlebotomist from The Whole List Doc. The purpose of this blood draw is to obtain specimens for laboratory testing. PROCEDURES: If you agree to this procedure, the following will happen. You will be asked to provide a current driver's license, a copy of your insurance card and when you started your fast. You will asked to fill out and sign the requisition form/forms. Blood will be taken from a vein in your right or left arm or the top of your right or left hand. Phlebotomy – the inserting of a needle into the arm of another person for the purpose of withdrawing blood. Finger Stick – the inserting of a lancet into the finger of another person for the purpose of withdrawing blood. The venipuncture may take place at 4605 Morse Rd Gahanna OH 43230 or another mutually agreed location. The blood draw will take about 20 minutes of your time. After the draw the blood is centrifuged, labeled, packaged and dropped off at the laboratory specified by your doctor. The total time of this procedure takes up to 90 minutes. RISKS/DISCOMFORTS: The risks of having blood drawn include temporary pain from the needle stick, bruising, and rarely, infection. Some patients may experience dizziness, possibly lightheaded or rarely fainting. In this case, the needle will be removed, and the RN /phlebotomist will proceed to keep the patient comfortable. AUTHORIZATION: I have read this consent form. All of the questions I have asked have been answered to my satisfaction. I agree to this procedure. *Patient's Signature *Clear SignatureDate *Submit
