PATIENT INFORMED CONSENT

    Email *


    PATIENT INFORMED CONSENT - MARYLEBONE DIAGNOSTIC CENTRE

    I understand that in the phlebotomy procedure, blood sufficient for the tests is removed as directed by my physician or phlebotomist.

    The procedures and risks have been explained to me. I have been given the opportunity to ask questions about the procedure and about the risks, hazards, and possible complications involved. I have discussed and understood alternative methods of phlebotomy with my physician or phlebotomist.

    I understand that there are no guarantees concerning the outcome of this procedure. All my questions have been answered to my satisfaction.

    In the event of a reaction or complication, the treating Medical Staff will provide immediate emergency medical care as indicated.

    I have been informed that all information obtained in connection with this procedure, including all test results and review of my medical history and records will remain confidential to the extent provided by UK regulation, and local law.

    I understand that the decision to participate is voluntary. I understand that I am free to withdraw my consent, via email.

    I hereby authorize that the blood cells removed from me be discarded appropriately.

    Do you consent *


    Name *


    DOB *


    Gender *


    This test needs 8-10 hrs of fasting *

    Are you fasting?


    Are you taking any medication or supplements? *


    List the medications or supplements you take *

    Did you have any surgery in the past? *


    List the surgeries you had*

    Do you suffer any disease? *


    List the diseases you have/had *

    E-Signature *