University of Louisiana at Monroe School of Pharmacy Patient Consent Form

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UniversityofLouisianaatMonroe
SchoolofPharmacy
PatientConsentForm
Name:_______________________________________ Today'sDate:__
__/____/____
(First)(MI)(Last)
Age:_____yearsold Birthdate:____/____/____
Race:
______________________ Smoker:☐Yes☐No
Fasting:_____(Yes,ifyouhavenothadanythingtoeatordrinkinthelast8hours
otherthanwaterorblackcoffee.)
CONSENTTOPERFORMLABORATORYTESTING
Theaboveinformationistruetothebestofmyknowledge.IauthorizetheUniversityof
Louisiana at Monroe to perform finger-stick blood testing. I understand that I am
financiallyresponsibleforanyfeestoperformthisservice.
Date:____________________
Patient
Signature:_____________________________________________________________
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