|
To the UMDNJ-University Hospital and the medical and nursing
personnel providing medical treatment to the following
patient:
| _______________________________________________ |
____ / ____ /____ |
| (Print Patients Name) |
(Date) |
Choose appropriate category:
______Category ONE: You are hereby notified
and instructed that I DO NOT WlSH any transfusion
of whole blood, red blood cells, white blood cells,
platelets or plasma to be used in my medical treatment,
and I understand the risks and benefits which have been
explained to me.
______Category TWO: You are hereby notified
and instructed that I wish to reduce my exposure
to blood transfusion. I request that methods be
employed to conserve and maximize my own blood supply
(if determined clinically necessary. I understand that
this approach to patient care will reduce but may not
completely eliminate the need for blood therapy at some
future point in my medical care.
I hereby release UMDNJ-University Hospital, its medical
and nursing personnel, officer, agents and employees
from any responsibility and liability for any personal
injury, damage or death that I may suffer and hereby
waive any and all claims and cause of action of every
nature and description against UMDNJ-University Hospital
which may result from my decision to refuse or
reduce my exposure to blood products.
The following alternatives to blood transfusion
are acceptable to me*:
* if my physician believes they are appropriate
| _______________________________ |
_______________________________ |
| (Patients Signature) |
(Witness Signature) |
| _______________________________ |
_______________________________ |
| (Patient Print Name) |
(Witness Print Name) |
|
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