Pre-Surgery Autologous Blood Donation Consent Form
Please complete this form to provide your consent and information for autologous blood donation prior to your surgery.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Scheduled Surgery Date
*
-
Month
-
Day
Year
Date
Type of Surgery
*
Have you previously donated blood?
*
Yes
No
Are you currently taking any medications?
*
Yes
No
Attending Physician's Name
*
Consent Declaration: I have read and understand the information regarding autologous blood donation. I consent to donate my own blood prior to my scheduled surgery and acknowledge the associated risks and benefits.
*
I agree and give my consent.
Submit Consent
Should be Empty: