Goodwill Healthcare Services Limited
01642 450770
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Phlebotomy Booking Form

Book your adult phlebotomy consultation with our clinical team. Please complete all sections — it only takes a few minutes.

Your Safety Comes First

We prioritise safe clinical practice.

We implement infection prevention and control measures to:

  • Prevent cross contamination
  • Maintain the quality of the sample collected
  • Ensure your general well-being during and after the sample collection

By completing the booking form below, you help us determine your suitability for a home-based phlebotomy appointment.

1 Patient Details
2 Screening
3 Test Selection
4 Disclaimers
5 At the Address
6 Consent
7 Appointment
8 Signature
Section 1

Patient Details

Section 2

Screening Questions

Please answer the required yes/no questions below. If yes, please provide details.

Do you have a history of fainting during blood tests? *

Do you have a history of difficult veins? *

Do you have any bleeding disorders (e.g. haemophilia)? *

Are you taking blood thinners (e.g. Warfarin, Apixaban)? *

Do you have any allergies (e.g. latex, antiseptics)? *

Section 3

Test Selection

Please clearly specify the test names.

I require the sample posting and agree to pay an additional fee at 0.45p/mile *

I require the sample dropping off at the lab (please note we will only deliver the sample to a lab within the locality and will calculate the mileage from AA route planner) *

Section 4

Important Disclaimers

I understand that this service is for blood sample collection only and does not include medical advice, diagnosis, or treatment. *

I understand that I am responsible for seeking advice from a qualified healthcare professional (e.g. GP) to interpret my results. *

I confirm that the information I have provided is accurate to the best of my knowledge. *

Section 5

At the Address

I will have someone at home with me when the phlebotomist attends *

I don't need support at home when I have the bloods collected *

There are no precautions the phlebotomist needs to take when they attend the property *

Section 6

Consent

I consent to blood sample collection. *

Would you like us to purchase the kit on your behalf? *

I agree for my details to be shared with the laboratory when Goodwill Healthcare Services Limited (GHS CARE) are requesting the kit for my blood collection. (Please note a service charge of £5 will be added to the total cost for this service) *

Section 7

Preferred Appointment

Choose the date and time you would like your consultation. We will confirm availability with you by phone or email.

Section 8

Agreement and Signature

I agree to make payment for the services I receive *

Step 1 of 8