Patient Consent Form | Theorem Metabolic

This consent form is required before we can perform a blood draw. Please complete all required fields and sign at the bottom. Your information is protected under UK GDPR and will only be used for the purposes outlined in our Privacy Policy.

Personal Details

Full Name *

Date of Birth *

Phone Number *

Email Address *

Home Address *

GP Details (Optional)

GP Name

GP Surgery Name & Address

Test Information

Test Panel Being Ordered

Consent Declarations

Consent to Blood Draw Procedure * I consent to having blood drawn by a qualified phlebotomist. I understand the procedure may cause minor discomfort, bruising, or in rare cases, fainting. I have been informed of the risks and benefits.

Consent to Receive Results * I consent to receiving my test results via the email address provided. I understand these results are for informational purposes only and do not constitute medical advice.

Consent to Share Results with GP (Optional) I consent to Theorem Metabolic sharing my test results with my GP if I have provided their details above.

Fasting Confirmation (if applicable) I confirm that I have fasted for the required period (typically 8-12 hours) if my test requires fasting. I understand that not fasting when required may affect my results.

Agreement to Terms * I have read and agree to the Terms & Conditions and Privacy Policy. I understand how my data will be collected, stored, and used.

Signature

Please sign below using your mouse, trackpad, or finger (on touch devices).

By signing above, I confirm that all information provided is accurate and I consent to the declarations marked above.

Today's Date *

Your form will be securely sent to info@theorem.fit