HIPAA Informed Consent

1

Patient Information

First name *

Last name *

Phone number *

Email address *

Date of birth — Month *

Day *

Year *

Are you 18 or older? *

Yes No

Street address *

City *

State *

ZIP *

2

Appointment Scheduling

Appointment date *

Appointment time *

Time zone

3

Purpose of Blood Draw

I acknowledge that a blood sample is being collected for laboratory testing, screening, or evaluation ordered by me or my healthcare provider.

4

Risks & Discomforts

• Mild discomfort, bruising, or bleeding
• Dizziness or fainting
• Rare risk of infection
• Rare risk of hematoma

5

Medical History & Safety Screening

6

Required Uploads

Upload Government ID *

Upload Lab Order or Specialty Kit Instructions *

7

Pre‑Procedure Acknowledgments

I understand the purpose of the blood draw.I understand the risks described above.I will follow pre‑procedure instructions (hydration, fasting if required, kit preparation).I understand my information is confidential under HIPAA.I acknowledge my right to ask questions at any time.

8

Consent Statements

I have been informed of the purpose and risks of the blood draw.I had the opportunity to ask questions and they were answered.I voluntarily consent to the blood draw.I authorize specimen collection and transport by Reddy LabSolutions LLC.I understand results are confidential and shared only with me unless I provide written authorization.I understand Reddy LabSolutions LLC provides specimen collection only and does not diagnose or treat.

9

Signatures

Sign by drawing, typing, or uploading an image of your signature.

Patient signature *

Phlebotomist signature (completed at appointment)

Signed — Month *