This document is a blood transfusion consent form for Miss. Ayesha Ajhar Shaikh, a 15-year-old female patient admitted to Sanjeevani Multispeciality Hospital on September 19, 2023. The form details the potential risks of blood transfusion that were explained to the patient, including transmission of infectious diseases. It also states that the hospital tests all blood for several diseases and infections. While no tests can guarantee that infections will not be transmitted, the patient understands the risks and provides consent for a blood transfusion if needed for her care. The form requires signatures from the patient, doctor, and witnesses.

1. Sanjeevani Multispeciality Hospital
Plot No. 17, Rishi Park, Ambad Chowfully, JALNA 431203
Blood Transfusion Consent
UHID : SHJ-124903 IPD Sr No : 17284
Patient Name : Miss. Ayesha Ajhar Shaikh DOA : 19-Sep-2023
Age /Sex : 15 / Female Time : 10:30:00 AM
Address : Partur Jalna Relative : .
Mobile : 9834274459 Relation : ..
Under Care of : Dr. Shivdas Mirkad, Contact No. : 9834274459
Room : 306 - Semi Special Company : Self
Dr.__________________________________________ has explained to me the Potential complications of transfusion of blood/
blood products which include the risk of transmission of infectious diseases such as Hepatitis ,HIV-AIDS and other bacterial and
parasitic diseases, allergic and febrile reactions etc.
I understand that all units of blood collected in the blood bank of Hospital are tested for antibodies to HIV1/ HIV2, Hepatitis C,
Hepatitis B, Surface Antigen, Syphilis(Rapid Plasma Regain Test) and screened for Malarial Parasite; and that only units that are
negative for these infectious diseases are released for transfusion; and that sterility checks and quality control procedures are
regularly performed on samples of blood components.
I also realize that no known test method can offer complete assurance that products derived from human sources will not transmit
infection.
I have read and understood this document and had a chance to clarify my doubts.
If need arises for the transfusion of blood /products as part of my care ,I here by give consent to such transfusion.
If patient is Unable to give consent the entire content may be explained to a relative, who signs mentioning the
relationship to the patient.
Patient Name:________________________________Signature:_________________Date:_____________Time:_____________
If patient is unable to sign, the name and relation of the person signing on his/her behalf
Name:______________________________________Signature:__________________Date:_____________Time:_____________
Doctor's
Name:_______________________________Signature:__________________Date:_____________Time:_____________
Witness on behalf at the Patient:
Witness Name:_______________________________Signature:__________________Date:_____________Time:_____________
Witness on behalf of the Hospital:
Witness Name:_______________________________Signature:__________________Date:_____________Time:_____________
Interpreter's Statement:
Specific language requirements (if any)
Interpreter services required: [ ] Yes [ ] No
I confirm that I have accurately interpreted the contents of this form, and the related conversation/s between the patient / person
giving consent and the doctor.
Interpreter's
Name:_______________________________Signature:__________________Date:_____________Time:_____________