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AccuGen Diagnostics LLC

1000 Iris Dr. SW Suite D-200 Conyers GA 30094

Phone Number: 470-610-3922

Informed Consent Form

Your safety is important to us. Please complete the form below to provide your information and confirm your consent for a phlebotomy blood draw appointment. AccuGen Diagnostics LLC. provides specimen collection only and does not diagnosis or treat. Submitting this form confirms your consent to proceed.

Birthday
Month
Day
Year
Are you 18 years of age or older?
Yes
No
Schedule an appointment
August 2026
SunMonTueWedThuFriSat
Week starting Sunday, August 2
Time zone: Coordinated Universal Time (UTC)Business location
Monday, Aug 3
10:00 AM - 11:00 AM
11:00 AM - 12:00 PM
12:00 PM - 1:00 PM
1:00 PM - 2:00 PM

Purpose of Blood Draw: I understand that a blood sample is being collected for the purpose of laboratory testing, health screening, or diagnostic evaluation as requested by myself or my healthcare provider.

Risks and Discomfort: I acknowledge that the blood draw procedure may involve the following risks: Mild discomfort, bruising, or bleeding at the puncture site. Dizziness, lightheadedness, or fainting. Rarely, infection or hematoma (a collection of blood under the skin)

Medical History: To ensure my safety during the procedure, I confirm the following:

Do you have a history of fainting or feeling lightheaded during blood draws?
No
Yes
Do you have any bleeding disorders or conditions that affect blood clotting?
No
Yes
Are you currently taking blood thinners or anticoagulants?
Yes
No
Are you pregnant or breastfeeding?
No
Yes
Do you currently have a fistula?
Yes
No
Do you have lymphedema?(swelling caused by a buildup of lymph fluid)
Yes
No
Have you ever had a mastectomy or had lymph nodes removed on either side?
Yes
No
I understand the purpose of this blood draw, and consent to the procedure?
No
Yes
Please be informed that there are potential risks and complications associated with blood draws, including bruising, infection, and fainting. Do you understand?
No
Yes
I agree to follow any pre-procedure instructions provided by AccuGen Diagnostics, such as fasting or hydration requirements.
I don't agree
I agree
I consent to the use of my blood sample for the specified tests and understand that my results will be kept confidential in accordance with HIPAA regulations.
No
Yes
I acknowledge that I have the right to ask questions and receive answers regarding the blood draw procedure.
No
Yes

Consent and authorization

  • I have been informed of the purpose and risks of the blood draw

  • I have had the opportunity to ask questions and all questions have been answered

  • I voluntarily consent to the collection of my blood sample by AccuGen Diagnostics LLC

  • I understand that my results will only be shared with me unless I provide separate written authorization

  • I understand that AccuGen Diagnostics LLC will maintain confidentiality in accordance with HIPPA and applicable privacy laws

Date
Month
Day
Year
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