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 Blood Draw Consent Form for Research – Used to obtain consent to collect a blood sample for research purposes.
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Importance of a Consent Form
Written consent is typically not required for routine blood work.[1] However, there are some instances where having proof of consent is essential, like when testing for a genetic condition or collecting blood from a minor. In these cases, a consent form shows that the patient (or their parent) understands the following:
- The medical purpose of the blood test
- The risks involved with collecting blood
- The confidentiality of testing results
- Their right to ask questions and discuss the procedure with the health care provider
Other information may need to be disclosed to patients depending on state laws and the nature of the blood test. For example, in New York, genetic testing results cannot be shared unless patients are informed of this policy and provide written consent.[2]
Sample
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BLOOD DRAW CONSENT FORM
I hereby consent for myself, or the person I am legally responsible for, to the drawing of a blood sample by [HEALTH CARE FACILITY’S NAME] (“Health Care Facility”) for the purpose of: [DESCRIBE REASON FOR SAMPLE].
I understand and accept that:
a. The risks involved with blood draws include, but are not limited to, discomfort at the site of the blood draw, possible bruising, redness and swelling around the site, bleeding at the sight, feeling lightheadedness when blood is being drawn, and rarely, an infection at the site of the blood draw.
b. Data derived from this blood draw is considered preliminary only and does not constitute any kind of diagnosis. It is my responsibility to initiate a follow-up examination to confirm results and obtain professional advice and medical treatment.
c. The Health Care Facility will keep my results confidential and may only release information to other organizations with my consent.
d. This consent is valid for [#] months, and I have the right to withdraw my consent at any time.
e. I am responsible for any cost not covered by my insurance for this blood draw, and I will receive a bill from the Health Care Facility for any non-covered cost.
I hereby release and forever discharge the Health Care Facility, its employees, agents, successors, and assigns from any and all claims, demands, actions, causes of action, or suits arising out of or in connection with the blood draw.
I have read (or someone has read to me) the information provided above and understand it. I have been given an opportunity to ask questions and all of my questions have been answered to my satisfaction.
Patient Signature: _____________________________ Date: ________
Printed Name: _____________________________
Parent/Guardian Signature: _____________________________ Date: ________
Printed Name: _____________________________