gowri test page blood transfusion

patientName

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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.