Informed consent for administration of blood or blood components (packed red blood cells, platelets, plasma, cryoprecipitate), including transfusion risks, alternatives, and pre-transfusion testing. Single signer (patient).
The Blood Transfusion Informed Consent 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 consent, blood transfusion, hematology, transfusion medicine, 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.
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# Blood Transfusion Informed Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Date:** ___________ **Facility Name:** ___________ **Ordering Physician:** ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number:** ___________ --- ## 1. Description of the Procedure A blood transfusion is the intravenous administration of blood or blood components collected from voluntary donors and processed by a licensed blood bank. All donated blood in the United States is tested by the blood supplier in compliance with FDA regulations before it is released for clinical use. **Blood component(s) planned:** ___________ **Estimated number of units:** ___________ **Route:** Intravenous (IV) infusion through a peripheral or central venous catheter. **Irradiation / leukoreduction / CMV-negative / other special requirements:** ___________ --- ## 2. Indication / Medical Reason This transfusion is recommended because: ___________ **Laboratory values supporting this decision (e.g., Hgb, Hct, platelet count, INR, fibrinogen):** ___________ ---