PLACE LABEL HERE
CONSENT FOR TRANSFUSION OF BLOOD PRODUCTS
I HEREBY AUTHORIZE DR. ______and/or such assistants as may be selected by him/her, to authorize the transfusion of blood products as deemed advisable in the management of my medical condition or any complications that may occur during this hospital stay. I understand that the blood product(s) to be administered to me will be supplied by a licensed blood supplier and that they are responsible for the collection, processing, testing and preserving of the blood products. I understand that despite all precautions, adverse reactions to this blood may still occur. These reactions/risksinclude but are not limited to: hepatitis, allergic reaction, transfusion related acute lung injury, fever, chills, West Nile Virus, volume overload, hemolysis. Other risks include the exposure to HIV, the Zika virus and other viruses, but this risk is very remote. No assurances or guarantees have been made to me about the outcome of the transfusion.
I understand that the benefitsof blood transfusion include improved oxygen delivery to vital organs, improved blood clotting and any other benefits discussed with my healthcare provider.
I understand that there are no artificial or natural substances which can perform all of the functions of blood. However, there are limited alternatives to transfusion, some of these alternatives include administration of hormones that stimulate the bone marrow (takes weeks to be effective), mineral supplements (takes weeks to months to be effective). None of these limited alternatives have been determined to be appropriate for my current condition.
BLOOD TRANSFUSION CONSENT
I give my informed, voluntary consent to the transfusion. I have been given an opportunity to ask questions.
______
Patient SignatureDateTime
The patient is unable to consent. I therefore consent for the patient.
______
Responsible Party SignatureDateTime
______
Printed nameRelationship to the patient
I have explained the procedure of transfusion, including the benefits, risks, possible adverse reactions, alternative treatment and anticipated results to the patient and/or their representative. The patient and/or their representative has communicated their understanding and have no further questions.
______
DateTimePhysician/LIP SignaturePID Number
EMERGENCY CONSENT
I have determined that the patient is in need of blood transfusion, aperson authorized to consent under Ga. Code 31-9-2 is not readily available, and any delay in this treatment could reasonably be expected to jeopardize the life or health of the patient.
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DateTimePhysician/LIP SignaturePID Number
VERBAL CONSENT
Verbal consent for blood transfusion obtained from ______by me
(Relationship if other than patient)
on ______at ______.
(Date) (Time)
______
DateTimePhysician/LIP SignaturePID Number
Dr. ______confirmed to me that verbal consent has been obtained from
______for blood product(s) transfusion.
(Patient/Authorized Person)
______
DateTimeNurse Signature
BLOOD TRANSFUSION REFUSAL
I DO NOT consent to the transfusion. I have been given an opportunity to ask questions. I have been advised of the benefits,risks, reactions, alternative treatment and anticipated results. I realize that I may die or suffer serious medical complications without this transfusion.
______
Patient SignatureDateTime
The patient is unable to consent. I therefore refuse this transfusion for the patient. I have been advised of the benefits,risks, reactions, alternative treatment and anticipated results. I realize that the patient may die or suffer serious medical complications without this transfusion.
______
Responsible Person’s SignatureDateTime
______
Printed Name Relationship to patient
I have explained the procedure of transfusion, including the benefits, risks, possible adverse reactions, alternative treatment and anticipated results to the patient and/or their representative. The patient and/or their representative have communicated to me that they understand this information and have no further questions. They are refusing transfusion.
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DateTimePhysician/LIP SignaturePID Number
FORM 2-26879 REV. 11/2016 Page 2 of 2