PERIPHERAL   BLOOD  COLLECTION 
INFORMED   NURSING   CONSENT

1.	I agree to the insertion of a peripheral blood collection device by a trained professional.

2.	The insertion procedure and complications have been explained to me 
and I understand them.

3.	I realize that this is an invasive procedure and has certain risks such as infection, bruising, vein inflammation and nerve damage.

4.	I understand that a needle no longer than one inch  will be placed in my arm.

5.	I have the right to voice any questions I may have about this procedure and I expect
	knowledgeable answers.  I also understand that there are specific policies relating to
	the care which will be given to me and include provisions for termination of services 
	at my request, the request of  physician, and/or at the decision of the agency. I agree
	to abide by the terms of these policies in all respects.

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Patient Signature								Date

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Witness									Date