Blood Test and Investigation Consent Form

Consent form for investigations

What blood test or investigation do you require?*
Why do you require this test to be done?*
I consent to having my tests being done and the results being sent to my:*
- Email address
- Home address
- To collect from Surgery myself
Email Address*
Address*
Street Address Address Line 2 City Postal Code Country
To collect from Surgery*
- 6-10 St. Georges Road, Wimbledon, London, SW19 4DP, United Kingdom
Acknowledgement
I acknowledge that the blood tests and other investigations are analysed and interpreted by a Third party who comply with the highest standards of clinical governance.
CONSENT
- I assume all responsibility for the results of my investigations.
- I agree that The GP Surgery Ltd takes no responsibility for my results.
- I am aware that The GP Surgery Ltd will contact me by telephone, Email or by post if there are any serious life-threatening irregularities with my investigations.
- I understand that I can discuss all investigation results over the phone using the ‘GP Results Interpretation Service’.
- The GP Surgery is not responsible for the patient not labelling their specimens accurately - so please make sure you check that your specimen is labelled appropriately.
- I consent to the GP using their clinical discretion to send any significantly abnormal results to my NHS GP.
- A haematoma (blood clot within the tissues) is a common side effect to having a blood test and I am prepared for this and the consequences of this after any blood test.
- If I have difficult veins, more than one attempt may be necessary.
Name of person having test*
First Last
Relationship (if patient is under 16 years old)
How are you related to the patient - Also state your name
I verify that I am the above patient/ representative and accept the terms and conditions*
- Yes I accept
Date*
Date Format: DD slash MM slash YYYY

Blood Test and Investigation Consent Form

Blood Test and Investigation Consent Form

Acknowledgement

CONSENT