This document is intended to serve as confirmation of informed consent for Blood Draw and Full Panel Testing.
I have informed the Halo Provider of all current medications and supplements. I have also informed Halo Med Spa of any known allergies to drugs or other substances, or of any past reactions to anesthetics.
I understand that I have the right to be informed of the procedure, any alternative options, and the risks and benefits of blood draw. Procedures will not be performed until I have the opportunity to give my informed consent, except in the case of an emergency. In case of emergency contact Dr. Don Hedges DO at Northwest Medical Center 505-345-3572 or northwestmedicalcenterinc.com
My signature below acknowledges that:
1. This procedure involves inserting a needle into the vein and drawing a vial of blood.
2. Alternatives to blood draw, but are not limited to, testing avalible with your primary care or specialty physician outside of Halo Med Spa.
3. The potential risks of blood draw include, but are not limited to:
I. Occasionally: Discomfort, bruising and pain at the draw site.
II. Rarely: Inflammation of the vein used for draw, phlebitis, metabolic
disturbances, and injury.
III. Extremely rarely: Severe allergic reaction, anaphylaxis, infection, cardiac
arrest, and death.
4. Benefits of Blood Draw and Full Panel Testing include:
I. Knowledge of baseline levels of the items listed on the TriCore order form reviewed with me by the Halo Provider.
I am aware that unforeseeable complications could occur, and I do not expect Halo Med Spa Provider to anticipate or explain all possible complications.
I rely on the Halo Provider to exercise judgement during the course of my treatment.
I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.
I understand that I have the right to consent or refuse any proposed treatment at any time.
My signature affirms that I have given consent to Draw blood with Halo Med Spa.
My signature below confirms that:
1. I understand the information provided on this form and consent to treatment.
2. The procedure(s) set forth above has been adequately explained.
3. I have received all the information and explanation I desire pertaining to the
procedure.
4. I authorize and consent to the procedure(s).
I fully understand Halo Med Spa does not give medical advise explaining results. You will need to visit your PCP or Don Hedges DO to discuss results.