Consent for transfusion of a blood component - template

I confirm that I have been unable to gain valid consent from the patient due to: (please state reason)

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………

OR

I confirm that I have:

  • Discussed theindication / reason for transfusion, benefits,material risks and reasonable alternatives to transfusion with the above patientprior to obtaining informed valid consent
  • Provided the relevant NHSBT transfusion patient information leaflet as part of the consent process,.allowing time for the patient to read it and ask any questions. If necessary, gave the leaflet in an alternative language to English
  • Where applicable, arranged for an interpreter so that the information is given to the patient in a way I believe they can understand
  • Explained to the patient that they can no longer donate blood.

Print Name...... Grade & Specialty......

Signature...... Date......

For further information, see overleaf

Consent for a blood transfusion

Information for healthcare professionals

Informed, valid consent for blood transfusion should be obtained and documented in the patient’sclinical record by the healthcare professional.

The key issues to be discussed when obtaining valid consent should be relevant for that patient, include the reason for transfusion, material risks, benefits and reasonable alternatives.

Utilise the NHS Blood and Transplant (NHSBT) patient information leaflets as part of the consent process as a standardised source of information for patients who may receive a transfusion. If your patientwas not able to give valid consent prior to the transfusion, please use ‘Information for patients who have received an unexpected blood transfusion’. All information leaflets are available to download at:

If consent is for a long term multi-transfused patient, check your organisation’s consent policy as a modified consent form may be available.

As material risks and reasonable alternatives can change over the course of time, and a risk can be seen as being material to one patient but not another; ideally consent should be ‘re-validated’ at least every 12 months.

Maintain and update your transfusion knowledge by completing the e-learning package at which includes a module on consent.

Further information:

1. Guideline on the investigation and management of acute transfusion reactions

2. Serious Hazards of Transfusion

NHSBlood and Transplant Patient Blood Management Practitioner Team Version 1, May 2016