Functional Labs Blood Draw - The Whole List Doc

TWLD 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 Ste 100 Gahanna OH 43230.  The blood draw usually takes about 30-60 minutes of your time. After the draw the blood is centrifuged, labeled, packaged and dropped off at the laboratory specified by your doctor at TWLD.

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.

CANCELLATIONS: We understand that emergencies do arise; however we request at least 24 hour notice for rescheduling or canceling all appointments. Failure to do so may result in your account to be charged. "NO SHOWS’ WILL BE BILLED FOR THE SCHEDULED BLOOD DRAW.

ARRIVALS: Please arrive for your appointment in our office on time. This ensures that you will receive the required amount of time you deserve for your treatment and helps us not to intrude on the following patients’ reserved time.

I have READ, UNDERSTAND AND CONSENT to the above.

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