Consent To Surgical Or Diagnostic And Anesthesia Page 2

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CONSENT FOR TRANSFUSION OF BLOOD
OR BLOOD PRODUCTS
1.
I consent to have blood and/or blood products transfusion(s) as may be deemed advisable by Dr.
____________________________
or his/her designee and the risks, of refusal, benefits, and alternatives to blood or blood product transfusions have been explained to me.
2.
I understand that no guarantee has been given by anyone as to the results that may be obtained.
3.
Potential benefits of receiving blood or blood products include:
•
Restoring blood volume
•
Replacing clotting factors; and
•
Improving oxygen delivery to the body.
4.
Potential risks of not receiving blood or blood products include:
•
Death
•
Heart attack
•
Stroke
•
Bleeding.
5.
I understand that reactions are very unusual. The potential risks of blood or blood products include, but are not limited to:
•
Temporary transfusion reactions such as headache, fever, chills, rash, and difficulty breathing;
•
Hepatitis;
•
Severe transfusion reactions potentially resulting in death;
•
HIV (Human Immunodeficiency virus) (AIDS); and
•
Other infectious agents.
6.
Potential alternatives to receiving community supplied blood or blood products include:
•
Donating my blood several weeks in advance;
•
Friends/relatives with compatible blood donating blood for me, if donated weeks in advance;
•
Cell saving technology (capturing and returning my own blood); and
•
Intravenous (IV) fluids to increase volume.
I, the undersigned, have had this blood / blood component and transfusion consent explained to me and fully understand the contents
of this authorization.
Signature of Patient or Authorized Person
Witness
Relationship of Authorized Person
Date
Time
REFUSAL OF BLOOD OR BLOOD PRODUCTS
I refuse the use of any blood and/or blood products. I understand the risks of not receiving blood and/or blood products.
Signature of Patient or Authorized Person
Witness
Relationship of Authorized Person
Date
Time
Patient ID Area
Form # NS180 (04/04)
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