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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.

 

Valid * Required
Valid * Required
Valid * Required
Valid * Required
Valid If patient, leave blank.
Valid If patient, leave blank.
Minor Blood Fractions
Valid * Required
Valid * Required
Valid * Required
Valid * Required
Equipment
Valid * Required
Valid * Required
Valid * Required
Valid * Required
Procedures
Valid * Required
Valid * Required
Valid * Required
Valid * Required

My signature above signifies that:

  1. I have read this document or have had it read to me and I understand and agree to the statements in this document.
  2. 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.
  3. All blanks or statements requiring completion were filled in before signed.
  4. 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.
  5. 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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