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Blood Transfusion Refusal

Blood Transfusion Refusal

For assistance with this form, please contact the AHN Office of Bloodless Medicine & Patient Blood Management at 412.359.8787.

I direct that no transfusions of:

  • whole blood
  • red cells
  • white cells
  • platelets
  • plasma

are to be given to me under any circumstances, even if physicians deem such necessary to preserve my life or health.  

Format m/d/yyyy
If patient, leave blank.
If patient, leave blank.
Procedures, Treatments, and Minor Blood Fractions
Minor Blood Fractions
A protein made by the liver. Albumin helps keep the fluid from the blood from leaking out into the tissue and helps maintain blood volume. A small amount of albumin may be used to buffer other medications, including erythropoietin (Procrit).
Natural erythropoietin is made by the kidneys. Recombinant (synthetic) erythropoietin is used to help build red blood cell volume in anemic patients. Procrit® (brand name) is buffered with a small amount of Albumin.
Found in some tetanus shots, also in snake or spider-bite anti-venom. Used in medications to fight diphtheria, hepatitis and rabies.
Used to stop bleeding and in some medical glues to seal wounds.
Maintains circulation during surgical procedures. Diverts the patient’s blood, oxygenates it, and directs it back to the patient.
Blood circulates through a machine that filters and cleans it before returning it to the patient.
– During surgery the patient’s blood is diverted into bags and replaced with a non-blood volume expander. During, or at the end of the surgery, the blood is returned to the patient.
Blood is recovered from an incision or body cavity during surgery, washed and filtered, and returned to the patient.
A small amount of the patient’s own blood (usually about an ounce) is withdrawn. It may be mixed with medicine, and is then returned to the patient. Time outside the body may vary.
A small amount of the patient’s own blood is injected into the membrane surrounding the spinal cord to seal a spinal fluid leak.
A small amount of the patient’s own blood (usually about an ounce) is withdrawn and concentrated into a solution rich in platelets and white cells. This solution is placed on surgical sites or wounds. Time outside the body may vary.

My signature above signifies that:

A. I have read this document or have had it read to me and I understand and agree to the statements in this document.

B. I have had the opportunity to ask questions and/or receive any additional information that I would require in order to make an informed decision.

C. All blanks or statements requiring completion were filled in before signed.

D. I fully understand the choice(s) that I have selected and accept any and all risks whether known or unknown, foreseeable or unforeseeable, including death, that may be involved.

E. I release all physicians, anesthesia personnel, Allegheny Health Network and its agents, servants and/or employees from any/all liability for damages that may be caused by my refusal of blood.

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