Alert Banner Warning

COVID-19 Vaccine Boosters

Alert Banner X

Booster eligibility requirements recently changed. See if you or your child are now eligible for a booster or additional dose. 

VIEW ELIGIBILITY DETAILS
search
search
toggle search inbox

I direct that no transfusions of:

  • Whole Blood
  • Red Cells
  • White Cells
  • Platelets
  • Plasma 

are to be given to me under any circumstances, even if physicians deem such necessary to preserve my life or health.

 

Minor Blood Fractions
Not quite. Try again.
  • accept
  • refuse
Not quite. Try again.
  • accept
  • refuse

My signature above signifies that:

  1. I have read this document or have had it read to me and I understand and agree to the statements in this document.
  2. I have had the opportunity to ask questions and/or receive any additional information that I would require in order to make an informed decision.
  3. All blanks or statements requiring completion were filled in before signed.
  4. I fully understand the choice(s) that I have selected and accept any and all risks whether known or unknown, foreseeable or unforeseeable, including death, that may be involved.
  5. I release all physicians, anesthesia personnel, Allegheny Health Network and its agents, servants and/or employees from any/all liability for damages that may be caused by my refusal of blood.