CONSENT & LIABILITY AGREEMENT

 

By signing this form, I voluntarily consent to allow B Positive Mobile Phlebotomy to collect and process specimens for laboratory testing. I understand the following terms:

 

Testing & Results:

 

Tests are for screening purposes only. It is my responsibility to consult a licensed healthcare provider for interpretation and medical advice.

 

Test results will be communicated through my preferred method (email, SMS, phone, or fax). I understand the risks of potential unauthorized disclosure.

 

Liability Waiver:

 

I release B Positive Mobile Phlebotomy, its employees, and representatives from any liability for adverse reactions, complications, or injuries related to the specimen collection procedure, including but not limited to bruising, infection, or fainting.

 

I acknowledge that mobile phlebotomy services are not a substitute for medical care or emergency services.

 

Payment Agreement:

 

I acknowledge that I am responsible for full payment at the time of service unless prior arrangements have been made.

 

Payment Methods Accepted: Credit Card, Check, or Cash (a 4% processing fee applies to credit card transactions).

 

Billing Responsibility: Patient

 

I understand that laboratory fees are separate from phlebotomy service charges and may be billed separately by the testing laboratory.

 

Service Fees:

 

Standard Mobile Draw Fee: $65 ($10 Per Additional Lab Order) 

Trip Fee (if applicable): Mileage Rate Based On Location

Cancellation Fee: 10% Of Lab Order  (Applies if appointment is canceled with less than 24 hours' notice)

 

Cancellation Policy:

 

Cancellations made within 24 hours of the scheduled appointment are subject to a cancellation fee.

No-shows will be charged the full service fee.

 

Acknowledgment & Authorization:

 

I acknowledge that I have read and understand the terms outlined above.

 

I authorize B Positive, Mobile Phlebotomy to collect my specimen(s) and release my test results to the ordering provider, if applicable.