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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the designated field at the top of the form. This identifies you as the patient making the refusal.
In the section labeled 'INITIAL those you are REFUSING', mark your refusal for each blood component by placing your initials next to Red Blood Cells, Platelets, Plasma, or any other specified option.
Review the list of alternatives to blood transfusion provided below. Check all options that you are willing to accept, ensuring you understand each alternative.
Sign and date the form at the bottom, confirming that you release your attending physicians and hospitals from responsibility regarding your refusal.
If applicable, have your authorized representative sign and date their section, indicating their relationship to you.
Finally, if you wish to revoke this refusal later, complete the revocation section at the end of the form.
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Ethical and legal aspects of refusal of blood transfusions by
by C Petrini 2014 Cited by 53 The patient, for his/her part, has the right to refuse blood transfusions on religious grounds (autonomy) provided he or she is competent and able to do so.
When a warrant is obtained to draw blood, the suspect is then subject to the States administrative sanctions for refusal, as well as criminal sanctions if the
I understand about the benefits of blood products, the risks of not receiving the transfusion, the alternatives and the risks of the alternatives. ☐ I consent
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