Refusal of Blood components/product administration

I __________________________________________ refuse to be administered the following

Name of Patient

☐ Blood
☐ Blood derivatives
☐ Blood and blood derivatives

In making my decision to refuse administration of blood components/products, I confirm the following:

◆ Doctor __________________________ and I have discussed the risks, including death, of not receiving blood
components/products during the following procedure: ____________________________________________
◆ I received information and was given the opportunity to ask questions about the benefits and risks of receiving
blood components/products. I am satisfied that my questions have been adequately answered and I fully
understand the risks and consequences that may occur as a result of my refusal.
◆ My doctor and I have discussed the possibility of using treatments other than blood components/products
which are appropriate for me. I understand the benefits and risks of these alternative treatments.
◆ I understand I have the right to change my mind at any time regarding this refusal. However, I also understand
there may be circumstances where it might be impossible to communicate my decision to cancel this refusal
(for example if I am unconscious during surgery)
◆ I have indicated the following special instructions: ________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
◆ I hereby release the hospital, its personnel, the attending physician, and any other person participating
in my care from any responsibility whatsoever for any injury or unfavorable consequences due to my
refusing the use of blood or its derivatives.

Date: ______________________________________Time ___________________________________AM/PM

Signature: _________________________________________________________________________________
(patient/legal representative)
If signed by someone other than the patient, indicate relationship: _____________________________________

Print name: ________________________________________________________________________________

(legal representative)

Signature: _________________________________________________________________________________
(witness)
Print name: ________________________________________________________________________________
(witness)