Consent For Blood Transfusion
Your doctor has advised that you receive a blood transfusion.
Your signature below indicates that:
1) You understand that you have the right NOT to have a blood transfusion at this time. You could wait to arrange for pre-donation of your own blood, or blood from a friend or relative (if compatible). You can waive this right if you do not wish to wait for treatment. Note that for urgent conditions, it may not be practical or safe to delay transfusion while awaiting pre-donation of blood. In this case, blood products from the blood bank will be used.
2) You understand that transfusion of blood involves certain risks including infection and allergic reactions and you have the right to either consent or refuse a transfusion.
All blood products are screened for disease before use according to strict standards of the US Food and Drug Administration (FDA). Although rare, it is still possible to transmit disease such as hepatitis B or C or HIV from a blood transfusion.
Before blood is administered, it is tested against a sample of your blood to be sure there will not be an allergic reaction (cross-matching). Therefore, the risk of an allergic reaction is very low (1 out of 14,000 cases). In extremely critical conditions there may not be enough time to perform a cross-match test.
3) You have received information from your physician concerning the risks and benefits of blood transfusion and any alternative therapies, and you have had the opportunity to discuss this matter with your physician.
4) Subject to any special instructions listed below, you consent to receiving a blood transfusion at this time.
(Describe here any specific instructions for patient's blood transfusion, for example, pre-donation, directed donation, etc.)
Signature: ________________________________ ______________________________
(Patient/parent/guardian) (Relationship to patient)
Witness: __________________________ Title: _________________
Date: __________________ Time: __________________