Phlebotomy Refusal Incident Form
Document a patient’s refusal of a phlebotomy procedure, reasons, informed discussion, and staff follow-up.
Patient Full Name
*
First Name
Last Name
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Refusal
*
Was the patient informed of the risks and alternatives?
*
Yes
No
Details of Information Provided to Patient
Staff Follow-Up Actions Taken
*
Staff Member Name
*
First Name
Last Name
Staff Position/Role
*
Date and Time Form Completed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit Incident Report
Should be Empty: