Blood Draw Log Form
Record and track details of each blood draw procedure accurately and efficiently.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient ID or Medical Record Number (if applicable)
Date and Time of Blood Draw
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Blood Draw (e.g., room number, clinic)
*
Phlebotomist Name
*
First Name
Last Name
Type of Specimen Collected
*
Please Select
Venous Blood
Capillary Blood
Arterial Blood
Other
Site of Blood Draw
*
Please Select
Left Arm
Right Arm
Hand
Fingerstick
Heelstick
Other
Volume Collected (mL)
*
Purpose of Blood Draw
*
Please Select
Routine Test
Emergency
Pre-Surgery
Research
Other
Any Complications or Reactions?
*
None
Bruising
Hematoma
Fainting
Other
Additional Notes / Comments
By signing below, I confirm that I have performed or witnessed the blood draw as documented above.
*
Submit Log Entry
Submit Log Entry
Should be Empty: