Preoperative Autologous Blood Donation Consent
Patient Name:
Date of Birth:
Hospital / Physician:
I have been informed about the purpose and procedure of preoperative autologous blood donation. I understand that this process involves donating my own blood prior to surgery so it can be used if a transfusion is necessary during or after my operation.
The risks and benefits of autologous blood donation, as well as alternatives, have been explained to me. I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
I consent to the collection, storage, and planned use of my own blood for transfusion related to my scheduled procedure.
Patient Signature:
Date:
Witness Signature:
Date:
Interpreter (if applicable):
Date: