The purpose of this consent form is to inform patients about the phlebotomy procedures performed at Natural Endocrinology Specialists (NES), PLLC.

The following procedures are performed at NES:

1. Phlebotomy – the inserting of a needle into the arm of another person for the purpose of withdrawing blood.
2. Finger Stick – the inserting of a lancet into the finger of another person for the purpose of withdrawing blood.

Risks Associated with Phlebotomy and Finger Sticks

While rare, there are risks associated with phlebotomy and finger sticks.

Risk from having blood drawn:

● Development of a hematoma at the site of venipuncture. This risk is minimized with good venipuncture technique and by maintaining appropriate pressure for an adequate time period at the site of the venipuncture.
● Drop in blood pressure so that you may feel dizzy and even possibly faint. It is important that you notify the phlebotomist if you feel any adverse symptoms at all during the procedure so that the venipuncture can be immediately stopped, and appropriate action taken.

Risk from having blood drawer:

● The main risk is transmission of communicable disease, i.e. HIV, Hepatitis C and Hepatitis B, in handling body fluids and needles. This risk is minimized by adhering to universal precautions, which are taught in the medical laboratory technician program. It is a risk common to all health care professionals.

All information regarding this form will be kept confidential. 

Informed Consent

As a patient of NES, I am aware of the possible risks and benefits associated with phlebotomy and finger stick procedures. I have read and understand the terms of this agreement and I hereby consent to the choices I have made above as my own free act.

If the patient is under 18 years of age, and not an emancipated individual, you must complete this form and it must be signed by a custodial parent or guardian.