Healthcare Plasma Consent Form

Healthcare Plasma Consent Form

Patient / Donor Information

Date of Birth:    Gender:

Insurance Information (if applicable)

Medical History & Screening

Have you ever had a severe reaction to blood or plasma donation? Yes No

Within the past 72 hours have you taken aspirin or other platelet-affecting medication? Yes No

Procedure Description, Risks, and Benefits

Procedure Description: I understand that plasmapheresis is a medical procedure in which whole blood is collected, plasma is separated from the cellular components, and the cellular components are returned to my circulation. The procedure will be performed by trained personnel using sterile disposable equipment. Expected duration is typically between 45 minutes and 2 hours depending on volume and device used. Planned donation date:

Risks: I understand that potential risks and complications include, but are not limited to: fainting or lightheadedness; bruising or hematoma at the venipuncture site; infection at puncture site; bleeding; nerve irritation; citrate reaction (tingling, numbness, muscle cramps) requiring calcium therapy; allergic reaction to anticoagulant or infusion fluids; hypotension; cardiac arrhythmia; and, rarely, severe reactions requiring hospitalization. I acknowledge that no guarantee can be given that all adverse events are listed here.

Benefits and Alternatives: I understand that the primary benefit of plasma donation is to provide plasma for therapeutic use. An alternative to donating is to decline or postpone donation. I have had the opportunity to ask questions and have received answers to my satisfaction regarding the procedure, risks, and alternatives.

Consent, Authorization & Confidentiality

Voluntary Consent: By signing below I voluntarily consent to undergo plasmapheresis and any associated venipuncture and monitoring. I understand that I may withdraw my consent and discontinue the procedure at any time prior to or during the donation without penalty. I agree to provide truthful and complete medical history and to follow staff instructions during the procedure.

Authorization for Treatment: I authorize trained personnel to administer emergency or supportive treatment if needed in the event of an adverse reaction, and to arrange for transfer to an emergency facility if necessary. I authorize emergency treatment as described

Confidentiality / HIPAA: I acknowledge that medical information related to this donation will be recorded and maintained by the facility. My health information will be used and disclosed as permitted by law for treatment, payment, and healthcare operations. I acknowledge receipt of the facility's privacy practices and authorize disclosure of relevant information to clinical personnel involved in my care. I acknowledge the privacy practices and consent to disclosures as described

Release & Certification

Release of Liability: By signing this form I release and hold harmless the collection facility, its employees and medical staff from liability for complications arising from the donation except in cases of gross negligence or willful misconduct. I certify that the information I have provided is true and complete to the best of my knowledge.

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