Informed refusal document for patients who decline all or specific blood products and transfusions, documenting the patient's understanding of medical risks and their voluntary, competent decision. Single signer (patient).
The Refusal of Blood Products is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (patient) and, by default, expires 30 days after it is sent if left unsigned. It covers refusal, blood products, informed refusal, autonomy, healthcare. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
Document Preview
# Refusal of Blood Products > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Date:** ___________ **Facility Name:** ___________ **Attending Physician:** ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number:** ___________ --- ## 1. Statement of Refusal I, the undersigned patient, am an adult of legal age and sound mind. I am making this decision voluntarily and without coercion. I hereby refuse the administration of blood and/or blood products as specified below. **Scope of refusal:** ___________ **Detail / exceptions (if any):** ___________ **Acceptable alternatives I authorize my physicians to use:** ___________ *Examples: IV iron, erythropoiesis-stimulating agents (epoetin alfa), cell-saver intraoperative autologous blood salvage, crystalloid and colloid volume expanders, antifibrinolytic agents (tranexamic acid, aminocaproic acid), recombinant clotting factors, normovolemic hemodilution using my own blood returned immediately — note any limitations or restrictions.* **Reason for refusal (optional — patient may decline to state):** ___________ --- ## 2. Understanding of My Current Medical Condition My physician has explained my current medical condition and why blood or blood products have been recommended: ___________