Consent For Blood And Blood Product Transfusion printable pdf download

Name

Consumer Number

Date Of Birth

Consent for Blood and

Chart Base

Blood Product Transfusion

This consent form authorizes ________________________________________ and his/her associates to administer

_____________________ for the treatment of _______________________________________________________.

I understand that State law guarantees my right to receive information about my health care and to make decisions

about my health care in partnership with my doctor. This document provides me with that information. In addition,

upon my request I have the opportunity to discuss this information further with my doctor.

PROPOSED TREATMENT

I understand that I need a transfusion as part of my treatment to correct a deﬁ ciency of my blood or its parts. This

transfusion may be needed for: too much blood loss due to injury, disease or surgery; treatment for cancer, leukemia,

or various blood diseases; replacing blood or blood parts that my body is unable to completely produce; or treatment

as part of organ or bone marrow transplantation.

I understand that the blood or blood products that I need may include any one or all of the following parts, depending

upon the nature of my medical condition:

• Red cells to carry oxygen to tissues or organs;

• Platelets to promote clotting;

• White cells to ﬁ ght infection;

• Plasma (the protein ﬂ uid part of blood) to replace the essential proteins needed for blood clotting; and

• Factor concentrates to replace essential proteins needed for blood clotting.

I understand that when my doctor decides I need a transfusion, a small blood sample will be collected and labeled

for testing prior to any transfusion. The sample will be sent to the Puget Sound Blood Center (“Blood Center”) for

transfusion testing to select a well-matched unit of donor blood. Before transfusion, the nurse will check the label and

my hospital armband to make sure that I am receiving the unit speciﬁ cally matched for me.

EXPECTED RESULTS AND BENEFITS

I understand that the transfusion of blood or its parts as listed above is being given to correct a deﬁ ciency. The beneﬁ ts

of this transfusion are expected to return my blood or its parts back to levels where they can perform their job in a

healthy way.

In the case of red cells, transfusion will very likely increase my blood oxygen carrying capacity and improve the

function of my heart and other organs. In the case of platelets, plasma, or factor concentrates, transfusion will very

likely improve my blood’s ability to form clots in order to minimize the risk of abnormal bleeding.

I understand that the transfusion procedure generally takes one to three hours and is given intravenously (by a needle-

like object typically inserted into a patient’s arm or hand).

Hospital Record or Outpatient Medical Record / Correspondence Section

MRF

Rev. Date 2006032

Page 1 of 3

DM-3295

Group Health Cooperative

Consent For Blood And Blood Product Transfusion