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    CONSENT TO RECEIVE BLOOD TRANSFUSION

    Uploaded by

    SimionThangadurai

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    CONSENT TO RECEIVE BLOOD TRANSFUSION

    Uploaded by

    SimionThangadurai
    1 views1 page

    Copyright

    © © All Rights Reserved

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    DOC, PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    1 views1 page

    CONSENT TO RECEIVE BLOOD TRANSFUSION

    Uploaded by

    SimionThangadurai

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
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    INFORMED CONSENT TO RECEIVE BLOOD TRANSFUSION

    Patient Name.......................................Age..................Sex.............Unique No....................

    IPD / OPD No.......................................Date...........................

    It has been explained to me that I need or may need blood / Components for myself / my
    patients………………IPD No……………, admitted under Dr…………………………
    It is also explained to me in the language I understand well that the chances for improvement or recovery
    will be helped by transfusion of blood / Components.

    I understand that the blood / Components to be transfused have been tested in accordance with the strict
    guidelines laid by the Drugs Controller of India and agree to any other extra tests done / technology used
    and costs incurred thereof, in order to make blood safer for transfusion. I understand that there are
    possible risks involved with blood transfusion including, but not limited to, transfusion of infections
    hepatitis, Acquired Immune deficiency Syndrome (AIDS) or certain others disease, unexpected blood
    reactions, such as immunization or allergic reaction. Although the transfusion reactions can be treated
    successfully, on very rare occasion it can be fatal.

    I have had an opportunity to ask questions regarding blood transfusion and all my queries are answered to
    my full satisfaction.
    I hereby give consent to ask questions regarding blood transfusion and all my queries are answered to my
    full satisfaction.
    I hereby given consent to administering blood/ Components myself / my patients

    Patient Name Sign Date Time

    Responsible Party’s Name & Relationship Sign Date Time

    PHYSICIAN DECLARATION: I have explained to the patient / responsible attendants the procedure and
    the risks benefits and alternatives (including the probable or likely consequences if no treatment is
    pursued). I have answered all the patient queries to the best of my knowledge; I believe that the patient
    has been adequately informed.

    The Patient and his family have been educated on the importance of Blood Transfusion and commonly held
    myths surrounding blood donation have been busted

    Physician Name Sign Date Time

    The right to refuse Transfusion

    I Do Not consent to a blood transfusion and I assume all risks and hazards that may occur due to this refusal
    to consent

    Patient / Responsible party’s Name Sign Date Time

    Witness Name Sign Date Time

    FORM NO

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