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VENIPUNCTURE LIABILITY WAIVER & CONSENT FORM -  IVY ONE, LLC

1. Consent for Venipuncture (Blood Draw)

I, the undersigned, voluntarily consent to undergo a venipuncture procedure, in which a sterile needle and catheter will be inserted into my vein for the purpose of intravenous access and collecting a blood sample. I understand this procedure may be performed by a licensed medical professional, phlebotomist, trained technician, or student nurse/trainee under appropriate supervision.

2. Acknowledgement of Risks

I understand that while venipuncture is generally a safe procedure, there are certain risks associated with it, including but not limited to:

  • Bruising or bleeding at the puncture site
  • Fainting or dizziness
  • Infection at the puncture site
  • Hematoma (a collection of blood under the skin)
  • Pain or discomfort
  • Nerve injury (rare)

I acknowledge that I have been informed of these potential risks and have had the opportunity to ask questions.

3. Release of Liability

In consideration of being allowed to undergo venipuncture, I hereby release, waive, and discharge Ivy One, LLC, its owners, employees, contractors, agents, and affiliates from any and all liability, claims, demands, actions, or causes of action arising out of or related to any loss, damage, or injury, including death, that may be sustained as a result of the venipuncture procedure.

I understand this release includes any claims based on negligence, action, or inaction by Ivy One, LLC and its staff.

4. Medical Disclosure

I affirm that I have disclosed any medical conditions, allergies (including latex), or medications that may affect the venipuncture procedure. I understand that failure to disclose relevant medical history may increase the risk of complications.

5. Right to Refuse or Withdraw

I understand that I have the right to refuse this procedure or withdraw my consent at any time before the procedure begins, without affecting my right to future care or services.

6. Authorization and Consent

By signing this waiver, I confirm that:

  • I have read and fully understand this form.
  • I have had all my questions answered to my satisfaction.
  • I voluntarily consent to the venipuncture procedure.
  • I release the facility and personnel from liability as outlined above.
  • I am over the age of 17 years. 


First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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