Blood Transfusion Refusal

For assistance with this form, please contact the AHN Office of Bloodless Medicine & Patient Blood Management at (412) 359-8787.

Refusal Form

I direct that no transfusions of:

are to be given to me under any circumstances, even if physicians deem such necessary to preserve my life or health.

Patient Name

Date of Birth

Email Address

Phone Number

Name of Person Filling out Form

Relationship to Patient

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Signature (Write your Full Name Here)

My signature above signifies that:

I have read this document or have had it read to me and I understand and agree to the statements in this document.
I have had the opportunity to ask questions and/or receive any additional information that I would require in order to make an informed decision.
All blanks or statements requiring completion were filled in before signed.
I fully understand the choice(s) that I have selected and accept any and all risks whether known or unknown, foreseeable or unforeseeable, including death, that may be involved.
I release all physicians, anesthesia personnel, Allegheny Health Network and its agents, servants and/or employees from any/all liability for damages that may be caused by my refusal of blood.