Blood transfusion consent template

Blood Transfusion Consent

Date: Date

I, Patient Name, file no. File Number, consent to receiving Blood Component, after Dr. Physician Name explained the reason it is needed, namely Reason Needed, its benefits, the possible risks including allergic reactions and fever, and the available alternatives.

I know I may refuse the procedure or withdraw my consent before it starts.

Patient: Patient Signature

Physician: Physician Signature

Witness: Witness Name – Signature: Witness Signature

Date and time: Date – Time