Blood Transfusion Consent Form
Patient Full Name
Date of Birth
Medical Record Number
Diagnosis / Reason for Transfusion
Risks, Benefits, and Alternatives Discussed
Patient / Legal Guardian understands the following:
Purpose and reason for the blood transfusion
Risks and potential complications involved
Possible alternatives to transfusion
Right to refuse transfusion
Additional Comments
Patient / Legal Guardian Signature
Date
Physician / Provider Signature
Date
Interpreter Signature (if applicable)
Date