INFORMED CONSENT FORM - BLOOD AND BLOOD PRODUCT TRANSFUSION
Download
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
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 | |||||||||
0 Response to "INFORMED CONSENT FORM - BLOOD AND BLOOD PRODUCT TRANSFUSION"
Post a Comment