Patient Service Agreement for Blood Draws

Date: [                        ]
Patient Name: [                                         ]
Appointment Date and Time: [                                        ]
Location Address: [                                                                                                                      ]
1. Purpose of Agreement
This agreement outlines the terms and conditions for blood draw services provided by Drawn To Royalty LLC. By signing this document, you acknowledge and agree to the following terms:
2. Patient Responsibilities
- Hydration: It is essential that patients are well-hydrated prior to the blood draw. We recommend drinking water at least 1-2 hours before your appointment. If fasting is required for testing, please consult with your provider beforehand.
- Behavior: Patients are expected to remain calm and cooperative during the blood draw. If any violent or resistant behavior occurs, the procedure may be halted for safety reasons, which could result in a non-refundable fee.
3. Special Considerations for Children
Parents or guardians are responsible for ensuring that children are calm and prepared for the procedure. If a child exhibits violent or resistant behavior, the blood draw may be postponed or canceled, potentially incurring a non-refundable fee.
4. Animals
To ensure the safety and well-being of all animals during blood draw procedures, we kindly request that:
- All animals are secured in a carrier or restrained in a manner that ensures their safety and comfort.
- Owners remain present to help calm their animals throughout the procedure.
If an animal shows signs of distress or agitation, we reserve the right to postpone the procedure to provide the best care for your pet, which may result in a non-refundable fee.
5. REQUISITION(S)
Providers must email a copy of your insurance card, signed acknowledgment, and all requisitions immediately before services are rendered. Failure to do so may result in the cancellation of your appointment.
Photo ID Required: Patients must present a valid government-issued photo ID at the time of service.
6. Non-Refundable Fees
Please be aware that if you are not adequately hydrated or if you exhibit violent or resistant behavior (or if a child does), the booking fees and any associated charges will be non-refundable.
7. Consent for Blood Draw
By signing this agreement, you consent to the collection of blood for diagnostic purposes and acknowledge that you have been informed about the procedure and its associated risks.
8. Acknowledgment
I understand that while blood work is a routine procedure, there are potential risks involved, including but not limited to:
- Discomfort or Pain: Some individuals may experience mild discomfort or pain at the site of the blood draw.
- Bruising or Swelling: There is a possibility of bruising or swelling at the puncture site.
- Infection: Although rare, there is a risk of infection at the needle insertion site.
- Inaccurate Results: Factors such as improper technique or handling may lead to inaccurate test results.
I acknowledge that I have been informed of these risks and understand that the staff will take all necessary precautions to minimize them.
I, the undersigned, have read and understood the terms of this Patient Service Agreement for Blood Draws. I acknowledge my responsibilities and agree to the policies outlined above.
Patient Signature: ___________________________
Date: ___________________________
Guardian Signature (if applicable): ___________________________
Date: ___________________________
This portal is designed to enhance the overall patient care experience by simplifying the scheduling process.

Print, sign, fax or email 24hrs. before appointment.