INFORMED CONSENT TO DRAW BLOOD

CONSENT FOR CARE

You approve, authorize Praesidium Diagnostics dba Sameday Health and Jeff Toll MD, and any employee working under the direction of the physician, to provide medical care, or to this patient for which you are the legal guardian. This medical care may include services and supplies related to your health (or the identified person) and may include (but not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale or dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment. 

You understand during the course of the proposed treatment(s), test(s), or examination(s) unforeseen conditions may arise which may necessitate additional treatment(s), test(s), or examination(s). You consent to the performance of additional treatment(s), test(s), or examination(s).


CONSENT TO DRAW BLOOD

You hereby give permission for a representative of Praesidium Diagnostics dba Sameday Health and Jeff Toll MD to obtain a sample of my blood for tests, which you have asked to be performed on said sample. You understand that a confidential copy of the results of this testing will be sent to the offices of Praesidium Diagnostics dba Sameday Health, Jeff Toll MD and the associated laboratory, my employer (if applicable), and to me via my preferred method (below). 

You understand your rights as a client in regards to HIPAA regulations; that information is confidential and shared with no one unless my permission is obtained; however, you are aware that during a venipuncture blood draw there’re always risks of bleeding, infection, and bruising.

You understand that a record of my treatment will be generated with each visit. We are committed to your privacy and all health care information provided to Sameday Health and affiliated companies will be protected. Any disclosures of PHI (protected health information) will therefore require authorization unless used in the following ways:

  1. Quality improvement regarding Sameday Health

  2. Health-related benefits and services referral

  3. Any court-ordered requests or subpoenas

  4. Any law or government mandates with an appropriate warrant

You understand the information provided on this form and agree to all therein. You understand that there is no implied or stated guarantee of success or effectiveness of any treatment. The procedures set forth above have been adequately explained to me by my provider. You understand that you are free to withdraw my consent and discontinue participation in their treatments at any time.

You understand that, except in emergencies, you must give 24 hours notice of intent to cancel or reschedule my appointment. You understand that you will incur the full fee for treatment, regardless of amount of supply used due to wasted materials.