INFORMED CONSENT FORM AND AUTHORIZATION FOR BLOOD TRANSFUSIONS AND/OR BLOOD DERIVATIVE PRODUCTS I.

Proposed Treatment: Your physician has explained that you need or might need a blood transfusion and/or its derivative products. The blood transfusion or its derivatives may be necessary because you suffer from the following condition or because you will be submitted to the following surgical procedure: ______________________________________________________________________ Blood transfusion or derivatives of blood may include one or several of the following products, depending on the nature of your medical condition: A. B. C. D. Red blood cells that transport oxygen to tissue and organs; Platelets that promote coagulation; White blood cells to combat infections; and/or Plasma (protein part of the blood) to replace the essential proteins necessary for blood coagulation. From the plasma, special products can be made for blood transfusions known as fractions of plasma (albumin, concentrated in the coagulation factor and immunoglobulins).

II.

Expected Results and Benefits: The purpose of a transfusion is that your blood or its derivative products return to the necessary levels for a healthy functioning. In the case of red blood cells, the transfusion can increase the level of oxygen in your blood and improve the functioning of your heart and other organs. In the case of platelets and plasma, it could improve your capacity to coagulate and therefore minimize the risk of abnormal bleeding. Risks and/or Complications: The transfusion or administration of blood derivatives, as any other medical treatment, implies some risks and there is no procedure or technique that can eliminate these completely. Because of the latter, the safety norms for the provision of blood transfusion and its derivatives are very strict. Nevertheless it is always possible to acquire diseases such as: viral hepatitis, Human Immunodeficiency Virus (HIV), syphilis or other transmittable diseases. After the performed blood transfusion, mild reactions may occur such as rashes, fevers and/or shivers. Although very rarely a hemolytic transfusion reaction may occur when the red blood cells in the blood transfusion dissolve. This type of reaction occurs when the donated blood and the receptor are not compatible. On the other hand, the fractions of plasma, although they do not provoke transfusion hemolytic reactions, may cause allergic reactions. Within the signs that may indicate an allergic reaction are the symptoms of fever, headache, uticaria, stomachache and vomiting. Usually, the majority of the patients do not manifest any reaction after receiving a blood transfusion. Medicine is not an exact science; therefore there is no absolute guarantee in the results and consequences of the blood transfusion or its derivatives, nor in the quality of the blood or its derivatives. Autologous Donations: In some circumstances it is possible that you donate your own blood before you summit yourself to an elective surgical procedure. Although this alternative eliminates transmission of infectious diseases that may cause adverse reactions and bacterial contamination, the autologous donation is not always available nor
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III.

IV.

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is it indicated for certain conditions that require transfusions. Please sign your initials in the appropriate option. _______ _______ V. I have made arrangements for an autologous donation. I have not made arrangements for an autologous donation.

Direct Donations: In occasions it is also possible to make arrangements for direct donations (family member or friend donation). Nevertheless direct donations have not yet been proven to be safer than voluntary donations (homologous donations). Please sign your initials in the appropriate option. _______ _______ I have made arrangements for a direct donation. I have not made arrangements for a direct donation.

VI.

Homologous Donations (from general inventory): When the available blood units have been exhausted, analogous or directs, or when there is no opportunity to plan the type of transfusion to be supplied, it may be necessary to recur to blood units from general inventory to continue the indicated treatment by your physician. Although these units are evaluated and analyzed to avoid the infection of a transmittable disease, a higher risk of contamination exists because these units may come from more than one (1) donor.

VII. Alternative Treatments: Due to the fact that each blood product has a specific function, there is a possibility that there is no other treatment for your condition that is not a blood transfusion or its derivatives. In some cases, depending on the medical condition, instead of the blood transfusion you can receive: A. Hemodilusion (the blood is removed before the procedure and is replaced with liquids), B. Blood Salvation (your blood is collected during the surgery), and/or C. Medications to reduce the necessity to receive transfusions. VIII. Authorization or Rejection: If my physician(s) and/or surgeon(s) determine(s) that a blood transfusion or its derivative is necessary: A. I GIVE my consent for the administration of the blood transfusions or derivatives that based on my physician(s) and/or surgeon(s) informed judgment are necessary. I offer my consent acknowledging that the blood transfusion or derivative vessels involve certain risks, including the transmission of diseases such as hepatitis or HIV. I understand that I have the right to request the provision of more information in reference of the benefits and more detailed information about the risks of the diverse options of blood transfusion or its derivatives. PATIENTS INITIALS: ______________________ B. I DO NOT ACCEPT blood transfusions or its derivatives. I refuse my consent acknowledging that not administering those blood transfusions or derivatives necessary based on my physician(s) and/or surgeon(s) informed judgment deterioration of my condition, post-operation complications and even death may present itself. Therefore, exercising my right to refuse blood transfusions and its derivatives, I relieve and for always exonerate the Hospital, its directors, employees, agents, insurance carrier and my physician(s) and/or surgeon(s) of civil and criminal responsibility for any damages I may suffer as a consequence of my decision. PATIENTS INITIALS: ______________________
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IX.

Final Acknowledgement and Reaffirmation of Consent: My signature in this form represents the following: A. Everything expressed before is correct and true; B. I read or was read to and understood the information provided in this form; C. I reaffirm everything I have recognized and accepted in this form and I do it voluntarily; D. I recognize that in the event in which any clause or part of this form is declared illegal or null by a Court, said declaration will not lessen the other clauses and its effect will be limited to the declared illegal or null clause.

AND TO CONFIRM, I SIGN THIS FORM. I sign this document on my behalf. In the event that the patient who receives the treatment is a minor or incapable to consent, my signature represents that I am the person entrusted and I have legal capacity to authorize and consent to what is expressed in this document in the name of the patient. ___/___/____ Patients Name: ____________________________________ Date:(month/day/year) Patients Time: ________ AM/PM Signature:________________________________________ If the patient cannot sign due to age minority or is physically or mentally impaired, please fill out the following information. Patients reason for not signing: [ ] Minority [ ] Impairment to consent [ ] Temporary [ ] Permanent Representative(s) Name(s): ______________________________________________ Representative(s) ID #: ___________________________ Representative(s) Signature(s): Representative(s) relation with the patient: [ ] Father [ ] Mother [ ] Son or Daughter [ ] Spouse [ ] Other: Explain: __________________________ Date: ___/___/____
(month/day/year)

Signature: __________________________________________ Signature: __________________________________________ Physicians Name: __________________________________________________ Signature:__________________________________________

Time: ________ AM/PM Date: ___/___/____

(month/day/year)

Time: ________ AM/PM

IMPORTANT NOTE: In the case of impairment due to minority, the consent of both parents (father and mother) is required, except in the case of an emergency certified by the physician. Every person that signs in representation of a patient must provide valid identification to be photocopied and attached to the consent form.
Rev. 05/2009

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