Form Phlebotomy Waiver Patient Information First Name Middle Name Last Name Birthdate Email Address City State Zip Phone Phlebotomy Procedure Consent and Liability Waiver Acknowledgment and Assumption of Risks I hereby acknowledge that I have voluntarily chosen to undergo phlebotomy procedures at Radiant Recharge. I understand that phlebotomy involves inserting a needle into a vein to draw blood, which will be used for therapeutic or diagnostic purposes. I acknowledge that, as with any medical procedure, there are inherent risks associated with phlebotomy, including but not limited to: Bruising, pain, or discomfort at the site of needle insertion Infection at the puncture site Lightheadedness, dizziness, or fainting Hematoma (a bruise or swelling due to blood leaking outside the vein) Nerve irritation or damage I understand that while the staff at Radiant Recharge will take all appropriate measures to minimize risks, not all risks can be eliminated. Consent to Proceed By signing this document, I affirm that: I have discussed any concerns I may have about the phlebotomy procedure with a healthcare professional at Radiant Recharge. I have had the opportunity to ask questions related to the procedure and have received satisfactory answers. I have informed the healthcare professional of my complete medical history, including any conditions or medications that may affect the outcome of the phlebotomy procedure. I consent to the performance of the phlebotomy procedure under the terms described herein. Release of Liability I hereby release Radiant Recharge, its employees, agents, and representatives, from any claims, liabilities, damages, or rights of action directly or indirectly arising from the phlebotomy procedure, except in cases of gross negligence or intentional misconduct by Radiant Recharge or its staff. I understand that this waiver does not affect my rights to seek recourse through insurance claims. Agreement I have read this consent and liability waiver form carefully and fully understand its contents. I am aware that this is a release of liability and a contract between myself and Radiant Recharge, and I sign it of my own free will. You may need to click the submit button twice.
