MCN’s customizable template, Refusal to Permit Blood/Blood Component Transfusion Form, is taken from our Outpatient Surgery and Ambulatory Services Policy and Procedure Manual. MCN Healthcare’s proven policy and procedure templates, competencies and compliance tools have assisted more than 20,000 health care organizations worldwide meet their regulatory compliance goals.

Health care organizations around the world utilize MCN’s compliant ready templates and workflow process tools to help them meet the latest changes in regulations and standards.

Here is some sample content from Refusal to Permit Blood/Blood Component Transfusion Form:

	REFUSAL TO PERMIT BLOOD/BLOOD COMPONENT TRANSFUSION I request that no blood derivatives be administered to during this visit. I hereby release , its personnel and the attending physician from any responsibility whatsoever for unfavorable reactions or any untoward results due to my refusal to permit the use of blood or its derivatives. The possible risks and consequences of such refusal on my part have been fully explained to me by my attending physician and I fully understand such risks and consequences may occur as a result of my refusal. Date: DOCUMENTO PARA RECHAZAR LAS TRANSFUSIONES...
Second excerpt:
	...que no se administre ningún derivativo de sangre a durante esta visita. Por medio de la presente, exonero , su personal y al médico del caso de cualquier responsabilidad en cuanto a reacciones desfavorables o cualesquiera resultados adversos debidos al rechazo por mi parte de permitir el uso de sangre o sus derivados. Los riesgos y las consecuencias posibles de este rechazo por mi part me han sido explicados totalmente por el médio de mi caso y comprendo totalmente que los...