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Consent For Procedure Essay

987 words - 4 pages


Certiˇed interpreter
(document in notes)


Procedure: __________________________________________________________________

_____________________________________________________________________________________________ .
I have talked with my provider about:
What the procedure is and what will happen before, during and after the procedure.

How it may help me (beneˇts).

The risks of the procedure.


Other options to this procedure (alternatives), including not having it done.

I have been given the chance to ask questions about the procedure. I understand results are not guaranteed.
...view middle of the document...

Court appointed guardian with judicial order in chart
Durable Power of Attorney for Health Care with Advance Medical Directive in chart
Legal next of Kin:

Spouse/domestic partner

Adult child


Adult sibling


For a non-emancipated minor, kinship maybe documented by #37148 Declaration of Responsibility for a Minorís Healthcare.




Witness to signature:



Witness to signature:



2nd witness only for phone / verbal consent or signature with X

Colby Campus ï 1321 Colby Ave.
Paciˇc Campus ï 916 Paciˇc Ave.
Pavilion for Women and Children ï 900 Paciˇc Ave.
Providence Regional Cancer Partnership
1717 13th Street ï Everett, WA 98201

(01/14) PAGE 1 OF 2
1162 (01/14/14)

Patient Name:_____________________________________
Birthdate: ________________________________________


Certiˇed interpreter
(document in notes)

If your provider believes you need or may need a transfusion of blood or blood components, then you have
been informed of:
What is a transfusion? The infusion of whole blood or blood components into your bloodstream. Blood
components may include whole blood, red blood cells, plasma, platelets and/or cryoprecipitate.

What are the beneˇts? A transfusion may provide life saving treatment or relieve symptoms caused by a lack of
blood or its components.


What are the risks? Risks include but are not limited to:
1. Common reactions which are usually not dangerous such as bruising, fever, chills and rash or hives.
2. Less common but more serious reactions such as shortness of breath, heart failure and kidney failure.
3. Extremely rare but possibly life-threatening reactions such as an infectious disease (e.g., hepatitis, HIV,
bacterial infection) or experiencing a hemolytic (blood cell breakdown) transfusion reaction.
Current blood bank testing and procedures...

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