Blood Transfusion Refusal

AHN will accommodate patients who opt out of receiving blood products during their care. Please complete the form below prior to a planned admission. It can also be completed after admission in the case of an emergency

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.

Patient Name

Date of Birth

Email Address

Phone Number

Name of Person Filling out Form