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Blood Transfusion Refusal

For assistance with this form, please contact the AHN Office of Bloodless Medicine & Patient Blood Management at
(412) 359-8787.

Refusal Form

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.

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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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