Required before service

Patient Consent

We need your written consent before performing phlebotomy, specimen collection, or any on-site service. Reviewing and signing this form takes about two minutes — and helps keep your care safe, transparent, and HIPAA-compliant.

Consent Document

ADEYSONS HEALTH LLC

9898 Bissonnet St, Ste 325E, Houston, TX 77036 · NPI #1194660787

1. Consent to Treatment

I voluntarily consent to the following services performed by a certified phlebotomist or authorized clinical-logistics professional employed or contracted by ADEYSONS HEALTH LLC (the "Company"):

Venipuncture / blood draw using sterile single-use needles and vacutainer tubes;
Capillary (finger-stick) blood collection;
Specimen collection — urine, saliva, oral or nasal swab, stool — as physician-ordered;
Non-diagnostic on-site supportive readings — blood pressure, pulse, oxygen saturation, glucose finger-stick — for patient comfort and visit documentation only. These readings are not a substitute for a clinical diagnosis and are not reported as laboratory results.

2. Risks & Discomfort

I understand venipuncture and specimen collection carry minor and ordinary risks including, but not limited to: temporary discomfort, bruising, bleeding, dizziness, fainting, hematoma, nerve irritation, or in rare cases infection at the puncture site. I will inform the phlebotomist of any bleeding disorder, anti-coagulant medication, recent vasovagal episode, latex allergy, or other relevant medical condition prior to the procedure.

3. HIPAA Notice of Privacy Practices

I acknowledge that I have been offered a copy of the Company's Notice of Privacy Practices in accordance with HIPAA, 45 CFR § 164.520. The Notice is published at adeysonshealth.com/privacy.

4. Financial Responsibility & Assignment of Benefits

I am financially responsible for any service not covered by my insurance carrier. I assign to ADEYSONS HEALTH LLC any benefits payable under my insurance plan and authorize the Company to release medical or billing information necessary for processing my claim.

5. Specimen Handling & Chain of Custody

I authorize ADEYSONS HEALTH LLC to label, transport, and deliver my specimen(s) under HIPAA-compliant chain-of-custody procedures to the reference laboratory ordered by my physician (Quest Diagnostics, LabCorp, or other physician-designated laboratory). I understand the Company does not perform diagnostic testing in-house and is not a CLIA-certified clinical laboratory.

6. Texas Patient Rights

This consent is obtained in accordance with Texas Health & Safety Code Ch. 241 and Texas Occupations Code Ch. 159 (Medical Privacy Act). I have the right to revoke this consent in writing at any time prior to service.

7. Photo & Video Release (Optional)

The optional checkbox below authorizes the use of anonymized photos or simulated-demonstration footage for marketing or educational purposes. Declining does not affect the services provided.

Service-Specific Addendum

9. On-Site CLIA-Waived Testing — Disclosures

The rapid point-of-care test(s) I am authorizing today are performed at ADEYSONS HEALTH LLC under CMS CLIA Certificate of Waiver #45D2344227 (ACTIVE, effective May 19, 2026 – May 18, 2028). I understand:

Scope of waived testing. Only FDA-cleared, CLIA-waived tests on the Certificate-approved list may be performed (e.g., Blood Glucose, HbA1c, Lipid Panel, Hemoglobin/Hematocrit, Urinalysis, Urine Pregnancy hCG, Rapid Strep A, Rapid Influenza A/B, Rapid COVID-19/RSV, Rapid Mono, Fecal Occult Blood, Prothrombin Time/INR).
Result reliability. Point-of-care results are screening tools. Equivocal, abnormal, or clinically inconsistent results may require confirmatory testing at a reference laboratory at additional cost.
No diagnosis. ADEYSONS HEALTH does not make clinical diagnoses. I will share my results with my own provider for diagnosis, treatment, and follow-up.
Result delivery. Results are released to me directly (and to my designated ordering provider if I name one) under Texas HB 300 §181.
Self-pay billing. Walk-in self-pay waived tests are paid at point-of-service; the Company will not separately bill my insurance unless I specifically request it.

Patient Information

Full legal name *Date of birth *Email *Phone *

If signing on behalf of a minor or incapacitated adult, fill these guardian fields:

Guardian nameRelationship

Acknowledgments

* I consent to phlebotomy, specimen collection, and non-diagnostic on-site supportive readings as described above. I understand the minor risks (bruising, bleeding, dizziness, hematoma, rare infection) and confirm I have disclosed any relevant medical conditions.* I acknowledge receipt of the ADEYSONS HEALTH LLC Notice of Privacy Practices (HIPAA, 45 CFR § 164.520), available at adeysonshealth.com/privacy.* I accept financial responsibility for any service not covered by my insurance and assign benefits payable to ADEYSONS HEALTH LLC.(Optional) I authorize the use of anonymized photos or simulated demonstration footage for marketing or educational purposes. Declining does not affect my care.

Your Signature

Sign with your finger, mouse, or stylus

Use your finger on a phone or trackpad — works on any device.

Prefer pen & paper? Download a printable copy of this consent on our official lab letterhead — sign it by hand and bring it to your appointment, or upload it above.

Once signed, a receipt is emailed to you and our records team. You will then be taken to checkout (if applicable).

Signed electronically under the Texas Uniform Electronic Transactions Act (TUETA) and the federal E-SIGN Act (15 USC § 7001).