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ATTACHMENT 6
HEPACO, INC.
CONSENT AND RELEASE – BLOOD TESTING
(To be Completed if Confirmatory Blood Test for Alcohol
is Requested by the Employee or Blood Test is Required by Law)
I freely and voluntarily request that a blood sample be taken from me and consent to the same
and its testing. I hereby release HEPACO, the _______________ laboratory and Dr./Clinic/ Hospital
________________, their employees, agents and contractors, from any liability whatsoever arising from
the request to furnish a blood sample, the testing of the blood sample and any decisions made on the
basis of the analysis. I further freely and voluntarily authorize the _______________ laboratory or
Dr./Clinic/Hospital ________________ to release to HEPACO all test results of the blood test.
Date Signature of Employee
Social Security Number
Date Signature of Witness
Document No. 804: Drug and Alcohol Abuse Policy
Revised December 2000 Attachment 6
