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Angel Touch Mobile Phlebotomy

Phone: 414-293-2806

Informed Consent

Your safety is important to us. Please complete the form below to provide your information and confirm your consent for a phlebotomy blood draw appointment. Angel Touch Mobile Phlebotomy provides specimen collection and does not diagnosis or treat. Submitting this form confirms your consent to proceed

Birthday
Month
Day
Year
Are you 18 years old or older?
Yes
No

Purpose of Blood Draw: I understand that a blood sample is being collected for the purpose of laboratory testing, health screening, or diagnostic evaluation as requested by myself or my provider.

Risks and Discomfort:  I acknowledge that the blood draw procedure may involve the following risks: Mild discomfort, bruising, or bleeding at the puncture site. Dizziness, lightheadedness, or fainting. Rarely, infection or hematoma (a collection of blood under the skin)

Medical History: To ensure my safety during the procedure, I confirm the follow:To ensure my safety during the procedure, I confirm the following:

Do you have a history of fainting or feeling lightheaded during blood draws?
Yes
No
Do you have any known allergies?
Yes
No
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