Mobile Phlebotomy Consent Form

Mobile Phlebotomy Informed Consent & Release of Liability
Patient Name
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Address
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1. Purpose of Mobile Phlebotomy Services

I, the undersigned, voluntarily consent to mobile phlebotomy services provided by Dripping Wellness, LLC ("Provider") and its authorized healthcare professionals. These services include but are not limited to venipuncture, blood collection, specimen handling, and transportation to a designated laboratory for analysis.

2. Risks & Acknowledgments

I understand that mobile blood draws are a safe and common procedure but may involve potential risks, including but not limited to: Bruising, bleeding, or swelling at the puncture site Pain or discomfort during or after the blood draw Dizziness or fainting related to blood collection Infection or hematoma at the puncture site (rare but possible)

I acknowledge that Dripping Wellness, LLC, its employees, and contractors are notresponsible for any adverse reactions, complications, or results beyond the standard risks associated with venipuncture.
3. Mobile Services & Liability Waiver

I understand that Dripping Wellness, LLC is providing mobile phlebotomy services at my request for convenience. I agree that:

Dripping Wellness, LLC and its employees are not responsible for lost, delayed, or mishandled specimens once delivered to the designated laboratory.

It is my responsibility to ensure that my lab requisition form and demographics sheet are provided at the time of service.

If I experience any adverse reaction, I will seek immediate medical attention and understand that Dripping Wellness, LLC is not liable for any resulting complications.

Dripping Wellness, LLC is not responsible for lab result interpretations; I will follow up with my ordering provider for results and medical advice.

4. I acknowledge that:

A concierge fee applies for mobile phlebotomy services.

If using insurance, I am responsible only for my lab copay.

Most insurance plans are accepted, but I will verify my coverage with my provider.

If my insurance does not cover the cost of my lab work, I am financially responsible

5. Release & Indemnification

I hereby release, indemnify, and hold harmless Dripping Wellness, LLC, its owners, employees, contractors, and affiliates from any and all claims, demands, losses, damages, liabilities, and expenses arising out of or related to my mobile blood draw services.
Consent & Authorization

I certify that:
I have read and understand this Informed Consent & Release of Liability Form.
I have been given the opportunity to ask questions and have received satisfactory answers.
I voluntarily consent to mobile phlebotomy services with full knowledge of the associated risks.
Patient Signature*

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Guardian Signature if applicable

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Relationship to Patient
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Dripping Wellness, LLC 7520 NW 5th Street Suite 200, Plantation, FL 33317
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Consent & Authorization