INFORMED CONSENT FORM - BLOOD AND BLOOD PRODUCT TRANSFUSION

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INFORMED CONSENT FORM BLOOD AND BLOOD PRODUCT TRANSFUSION
PATIENT’S NAME							UID
Gender				Age				WARD / BED NO.
S. N.	DESCRIPTION
1.	I here by authorize Dr……………………………………………………………………………….. for transfusion of blood or blood product (……………………) on myself / my patient ………………………………………. ………………………………..(name of patient). I have been explained the purpose, benefits, risks and alternatives of blood / blood product transfusion (including its risks). I have also been explained the consequences of not getting the blood or blood product transfusion.
2.	Benefit: Blood and blood transfusion benefits patients by treating the blood loss or blood component loss. As blood and blood components are vital to life, it is considered as a life saving treatment. Risks: I understand that Blood and Blood product transfusion is associated with certain risk. Some general risks of transfusion are given below Mild reactions leading to itching, fever, rashes, headaches (1-5% chance) Shortness of breath, (<1% chance) Blood borne infection (<1% chance) Reduction in immunity (<1% chance) Shock (<1% chance) Exposure to blood borne viruses such as hepatitis, HIV (Extremely rare) Death (Extremely rare) Specific risks depending on patients’ condition ______________________________________________________________ _____________________________________________________________ Alternatives: _____________________________________ _____________________________________
3.	Consequences of refusal: Not taking blood or blood product transfusion treatment in my case can lead to following consequences, __________________________________________ __________________________________________
4.	I also acknowledge that I have truthfully disclosed, to the best of my knowledge, all medical history and condition, asked to me, by my doctor.
Signature and name of the person giving consent								Date / Time
Relationship with the patient
Signature and name of the witness								Date / Time
Signature and name of the doctor taking consent								Date / Time

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