The State of Queensland (Queensland Health), 2011

Permission to reproduce should be sought from [email protected]

(Affix identification label here)

URN:
Family name:

Blood and Blood Products

Transfusion Consent

Given name(s):
Address:
Date of birth:

Facility:

A. Interpreter / cultural needs

An Interpreter Service is required?

Yes

No

If Yes, is a qualified Interpreter present?

Yes

No

A Cultural Support Person is required?

Yes

No

If Yes, is a Cultural Support Person present?

Yes

No

B. Why am I having a transfusion?

...........................................................................................................................................................................

...........................................................................................................................................................................

Your medical condition requires the following blood

product/s. DOCTOR TO INDICATE PRODUCTS
Red Cells
Platelets
Fresh Frozen Plasma
Cryoprecipitate

Eg. 10/01/2008
Approximate end Date of
Transfusion. Eg. 20/06/2008.
A new consent is required after 12
months from start of transfusion.

C. Risks of blood and blood products

transfusion consent
Most common reactions to fresh blood or blood
products that are being transfused are:
high temperature
rash, itching and hives
feeling a bit unwell.
Rare risks are:
having too much blood/fluids giving you shortness
of breath.
haemolysis, the abnormal breakdown of red blood
cells.
the development of antibodies which may
complicate future transfusions and/or organ or
tissue transplants. If these complications develop
in women they can potentially cause problems for
all current and future unborn babies.
lung injury causing shortness of breath.
the spread of viral or other infectious germs from
the blood of the donors.
very rarely, these above reactions can cause
severe harm or possibly death.
There are specific problems for long term multiple
transfusions that may be relevant to your medical
condition. Your Doctor will discuss these with you

D. Other relevant treatment options

In some situations there maybe other choices to a
blood transfusion and these include fluid
replacement with saline or other artificial compounds
and/or iron supplements.
Your Doctor will discuss these with you as some
choices are not suitable for everybody.
(Doctor to document in space provided. Continue in
Medical Record if necessary.)

PROCEDURAL CONSENT FORM

Your doctor has recommended that you have a

transfusion of blood or blood products, which are from
volunteer donors. Blood is collected and screened by
the Australian Red Cross Service.
A transfusion is necessary to replace a part of your
blood and is given to either;
replace red blood cells to treat or prevent
anaemia, improve oxygen transport and relieve
symptoms of dizziness, tiredness or shortness of
breath or
to give you platelets to help stop or prevent
bleeding or
to give a fresh plasma product to stop, treat or
prevent bleeding.
Transfusions are given via cannulae (needle in your
vein) or via a central line into your vein. During your
transfusion you will be closely watched for any
possible reactions. You will also be regularly checked
as to whether you may need another blood
transfusion.
The doctor has explained that I have the following
medical condition for which I need a transfusion:
(Doctor to document in patients own words)

DO NOT WRITE IN THIS BINDING MARGIN

Start Date of Transfusion

This consent primarily includes intravenous or central

venous line infusion of fresh blood and blood
products, red cells, platelets and plasma (e.g. fresh
frozen plasma and cryoprecipitate)

v5.00 - 05/2011

Sex:

...........................................................................................................................................................................

SW9002

FREQUENCY OF THE TREATMENTS. (Doctor can

specify that the frequency may vary during the course
of treatment) .................................................................................................................................

...........................................................................................................................................................................

...........................................................................................................................................................................

...........................................................................................................................................................................

Page 1 of 2

Continues over page

(Affix identification label here)

URN:
Family name:
Given name(s):
Address:
Date of birth:

Facility:

Sex:

E. Risks of not having the blood and/or

blood products transfusion

I request to have the procedure

(Doctor to document in space provided. Continue in

Medical Record if necessary.)

Signature: ..........................................................................................................................................

Name of Patient: ..........................................................................................................................

Date: ......................................................................................................................................................

............................................................................................................................................................................

............................................................................................................................................................................

............................................................................................................................................................................

F. Patient consent

Blood & Blood Products Transfusion

Consent
Blood who needs it? A consumer
brochure

Consent must be obtained from a substitute decision

maker/s in the order below.
Does the patient have an Advance Health Directive
(AHD)?
Yes

Location of the original or certified copy of the AHD:

................................................................................................................................................................

No

Name of Substitute
Decision Maker/s: ...............................................................................................................
DO NOT WRITE IN THIS BINDING MARGIN

I acknowledge that the doctor has explained;

my medical condition and the proposed
procedure, including additional treatment if the
doctor finds something unexpected. I understand
the risks, including the risks that are specific to
me.
other relevant procedure/treatment options and
their associated risks.
my prognosis and the risks of not having the
procedure.
that no guarantee has been made that the
procedure will improve my condition even though
it has been carried out with due professional care.
if immediate life-threatening events happen
during the procedure, they will be treated based
on my discussions with the doctor or my Acute
Resuscitation Plan.
I have been given the following Patient
Information Sheet/s:

Patients who lack capacity to provide consent

Signature: .....................................................................................................................................
Relationship to patient: .................................................................................................
Date: ....................................................... PH No: ..................................................................
Source of decision making authority (tick one):
Tribunal-appointed Guardian
Attorney/s for health matters under Enduring Power
of Attorney or AHD
Statutory Health Attorney
If none of these, the Adult Guardian has provided
consent. Ph 1300 QLD OAG (753 624)

G. Doctor/delegate Statement
I have explained to the patient all the above points
under the Patient Consent section (F) and I am of
the opinion that the patient/substitute decisionmaker has understood the information.
Name of
Doctor/delegate: .......................................................................................................................

Blood Transfusion- Questions to ask

your doctor

Designation:..................................................................................................................................

Blood components: A guide for patients

I was able to ask questions and raise concerns
with the doctor about my condition, the proposed
procedure and its risks, and my treatment
options. My questions and concerns have been
discussed and answered to my satisfaction.
I understand I have the right to change my mind
at any time, including after I have signed this form
but, preferably following a discussion with my
doctor.
I understand that image/s or video footage may
be recorded as part of and during my procedure
and that these image/s or video/s will assist the
doctor to provide appropriate treatment.
On the basis of the above statements,

Signature: ........................................................................................................................................
Date: ......................................................................................................................................................

H. Interpreters statement
I have given a sight translation in
.....................................................................................................................................................................

(state the patients language here) of the consent

form and assisted in the provision of any verbal and
written information given to the patient/parent or
guardian/substitute decision-maker by the doctor.
Name of
Interpreter: ......................................................................................................................................
Signature: ........................................................................................................................................
Date: ......................................................................................................................................................

Page 2 of 2

05/2011 - v5.00

Blood and Blood Products

Transfusion Consent

 The State of Queensland (Queensland Health), 2011

Permission to reproduce should be sought from [email protected]

Consent Information - Patient Copy

Blood and Blood Products Transfusion Consent
Please discuss these options with your doctor as they
are not suitable for everybody.

1. Why am I having a blood and/or blood

products transfusion?
Your doctor has recommended that you have a
transfusion of blood or blood products, which are from
volunteer donors. Blood is collected and screened by
the Australian Red Cross Service.
A transfusion is necessary to replace a part of your
blood.
A transfusion is given to either;
replace red blood cells to treat or prevent
anaemia, improve oxygen transport and relieve
symptoms of dizziness, tiredness or shortness of
breath or
to give you platelets to help stop or prevent
bleeding or
to give a fresh plasma product to stop, treat or
prevent bleeding.
Transfusions are given via a cannula (needle in your
vein) or a central line into your vein. You will be closely
watched for any reactions. You will also be regularly
checked as to whether you need another blood
transfusion.

Extra written information is available and may include:

Blood who needs it? A consumer brochure
(Australian Government - National Health
Medical Research Council)
http://www.nhmrc.gov.au/_files_nhmrc/file/
publications/synopses/cp83.pdf
Blood Transfusion Questions to ask your

doctor.
(Australian Red Cross Blood Service)
http://www.mytransfusion.com.au/node/ques
tions-ask-your-doctor
English and multicultural patient information
leaflets are available.
http://www.cec.health.nsw.gov.au/resources/
More detailed information can be found at
the following websites.
Blood Components: A Guide for Patients

(National Health Medical Research Council)

2. What are the risks of having a blood or

blood products (fresh) transfusion
Most common reactions to the blood and blood
products that are being transfused are:
high temperature
rash, itching and hives
feeling a bit unwell
Rare risks are:
having too much blood/fluids giving you shortness
of breathe.
Haemolysis, the abnormal breakdown of red blood
cells
the development of antibodies which may
complicate future transfusions and/or organ or
tissue transplants. If these complications develop
in women they can potentially cause problems for
all current and future unborn babies.
lung injury causing shortness of breath.
the spread of viral or other infectious germs from
the blood of the donors.
very rarely, these above reactions can cause
severe harm or possibly death.

05/2011 - v5.00

3. What are other relevant treatment options

that you may have?
In some situations there may be other choices to a
blood transfusion and these include- fluid replacement
with saline or other artificial compounds and/or iron
supplements.

http://www.nhmrc.gov.au/_files_nhmrc/file/p
ublications/synopses/cp85.pdf
Australian Red Cross Blood Service

http://mytransfusion.com.au/
All sites provide excellent information,
including statistical information.

Notes to talk to my doctor about:

...........................................................................................................................................................................

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...........................................................................................................................................................................

...........................................................................................................................................................................

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...........................................................................................................................................................................

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