INFORMED CONSENT FORM

BLOOD AND BLOOD PRODUCT TRANSFUSION

PATIENT’S NAME UID

Gender Age WARD / BED NO.

S. N. DESCRIPTION

1.
I here by authorize Dr……………………………………………………………………………….. for transfusion of
blood or blood product (……………………) on myself / my patient ……………………………………….
………………………………..(name of patient). I have been explained the purpose, benefits, risks and
alternatives of blood / blood product transfusion (including its risks). I have also been explained the
consequences of not getting the blood or blood product transfusion.

2. Benefit: Blood and blood transfusion benefits patients by treating the blood loss or blood component loss. As
blood and blood components are vital to life, it is considered as a life saving treatment.

Risks: I understand that Blood and Blood product transfusion is associated with certain risk. Some general
risks of transfusion are given below
 Mild reactions leading to itching, fever, rashes, headaches (1-5% chance)
 Shortness of breath, (<1% chance)
 Blood borne infection (<1% chance)
 Reduction in immunity (<1% chance)
 Shock (<1% chance)
 Exposure to blood borne viruses such as hepatitis, HIV (Extremely rare)
 Death (Extremely rare)
Specific risks depending on patients’ condition
______________________________________________________________
_____________________________________________________________
Alternatives:
 _____________________________________
 _____________________________________

3. Consequences of refusal: Not taking blood or blood product transfusion treatment in my case can lead to
following consequences,
 __________________________________________
 __________________________________________

4. I also acknowledge that I have truthfully disclosed, to the best of my knowledge, all medical history and
condition, asked to me, by my doctor.

Signature and name of the person giving Date / Time

consent

Relationship with the patient

Signature and name of the witness Date / Time

Signature and name of the doctor taking Date / Time

consent