Here is our consent - a little long winded but seems to cover everything. They get it from the referring Physician. I consent to the procedure known as Therapeutic Phlebotomy for the treatment of a condition explained to me as _________________________ by Dr. __________________, who also explained the benefits and alternative treatments. I understand that in the phlebotomy procedure one pint (or less) of blood is removed as directed by Dr. __________________. I understand that I may have pain, discomfort, bruising, clotting and rarely infection at the site of the blood drawing. Symptoms such as sweating, nausea, or even fainting may sometimes occur. In addition, there may be unforeseen risks. However, I still willing to accept responsibility of these. I understand that if I have any questions regarding the purpose of the phlebotomy procedure and its usefulness, the hazards involved in it, or any related questions, I am free to ask them at any time and have them answered to my full and complete satisfaction. Print Name_______________ Signgnature__________________ Witness______________ Date______________