Form Inform Consent Transfusi Darah

 

 K`. NG :  K`. UL :  Kclc Qcsnhk :  Kclc Neu Dckguko :

QHUVHWXJXCK / QHK@ICDCK)* WNKGCDCK WUCKVBXVN GCUCM QHLEHUNCK NKB@ULCVN JHKNV WNKGCDCK : WUCKVBXVN GCUCM  Kclc GQJQ Qhlehrn Nkb`rlcsn Qhkhrnlc nkb`rlcsn/phlehrn  phrshtujuck * Gnehrndck pcgc wcdtu

K@

JHKNV NKB@ULCVN

3

Qh Qhko kohr hrtn tnck ck Wr Wrck cksb sbus usnn Gcrcm

5

Jhkn Jhknss Gcrc Gcrcm m / D`lp D`lp`k `khk hk Gcrcm

6

Wuju Wujuck ck / Nkgn Nkgnd dcsn csn Wrcksbusn Gcrcm

7

Un Unsn snd` d` / D` D`lp lpin indc dcsn sn

8

Wctc Fcrc

2

Icnk-icnk

Wckooci :

J cl :

NVN NKB@ULCVN Vu Vuct ctu u pr`sh pr`shss lh lhlc lcsu suddc ddck k d`lp d`lp`k `khk hk gcrc gcrcm m gcrn gcrn `rck `rcko o shmc shmctt (G (G`k `k`r) `r) dhgc dhgcic icl l tueu tueum m `rc `rcko ko sc scdn dntt (Qcsnhk) shfcrc nktrcvhkc. D`lp`khk gcrcm ycko thrshgnc shecocn ehrndut : Gcrcm phkum (_m`ih (_m`ih Ei``g )  Qcfdhg Uhg Fhii  (QUF)   (QUF) Wmr`le`fyth F`kfhktrcth (WF) F`kfhktrcth  (WF)  Brhsm Br`zhk Q Qicslc icslc (BBQ)  (BBQ) Fry`prhfnpntcth Gcrcm lhrcm fufn (_csmhg (_csmhg Uhg Fhii ) D`lp`k D`l p`khk hk gcr gcrcm cm thrshe thrsheut ut gne gnehrn hrndck dck dhp dhpcgc cgc pcs pcsnhk nhk shsucn nkgndcsn. Ckhlnc dcrhkc phrgcrcmck cdut. Ckhlnc dr`knd. Qhrgcrc Qhrg crcmck mck dcr dcrhkc hkc dhd dhdurc urckoc kock k d`l d`lp`k p`khk hk gcrc gcrcm m (tr`le`snt, bcft`r phlehduck) Qicslc i`ss ctcu mnp`cieulnkhlnc jndc tngcd gcpct gnehrndck picslc suestntuth ctcu icrutck cieulnk D`lp D`lpin indc dcsn sn trck trcksb sbus usnn gc gcrc rcm m gc gcpc pctt gneh gnehgc gcdc dck k ctcs ctcs : 3. D`lp D`lpin indc dcsn sn lh lhku kuru rutt dhth dhthrin rinec ectc tck k sn snsth sthl l nluk nluk tueum : c. D`l D`lpin pindcs dcsnn nlu nluk`i k`i`on `on (eh (ehrmu rmueuk eukock ock ghk ghkock ock rhcdsn trcksbusn)  e. D`lpindcsn k`k nluk`i`on (gnshecedck hbhd  bnsnd gcrn d`lp`khk gcrcm gck nkbhdsn) 5. D`lpi D`lpindcsn ndcsn lhkuru lhkurutt wcdtu phlehrnc phlehrnck k trcksbusn : c. D`lpi D`lpindcsn ndcsn shohrc (nllhgncth nllhgncth))  e. D`lpindcsn thrtukgc (ghicyhg ) 3. Qcgc pcsnhk gnicdudck phkoclenick f`kt`m gcrcm  pcgc gcrcm vhkc 8 li uktud f`kt`m gcrcm. Jndc Jndc jcrc jcrcd d ckt cktcrc crc 5 dci dcinn tr trck cksbu sbusn sn ihenm ihenm gcr gcrnn 57  jcl, gnphriudck f`kt`m gcrcm ecru. 5. F`kt`m gcrcm gck b`rluin b`rluinrr phrln phrlnktcck ktcck gndnrnl dh Xknt Wrcksbusn Gcrcm UVN Vuitck Couko ctcu QLN 6. Vhthicm Vhthicm gcrc gcrcm m trcksb trcksbusn usn gctcko gctcko,, lcd lcdcc gni gnicdu cdudck dck  pr`shgur trcksbusn gcrcm. 7. Jhk Jhkns ns gck julic julicm m trc trcksb ksbusn usn gcrc gcrcm m yck ycko o gne gnehrn hrndck dck shsu shsucn cn gh ghko kock ck dh dheu eutu tumc mck k lh lhgn gnss gc gcrn rn pc pcsn snhk hk thrsheut. 3. Qhlencycck gcrcm trcksbusn gntckoouko `ihm pcsnhk gck/ctcu dhiucroc pcsnhk thrlcsud gcrcm trcksbusn ycko sugcm gnphsck gck/c gck/ctcu tcu gnehin lhsdnpuk tngcd  thrpcdcn/snsc ycko gndcrhkcdck dhcgcck pcsnhk. 5. …………………………………………………… …………… 6. …………………………………………………… ………….... 7. .................................................................................. ......................

WCKGC (√ )

 

Ghkock nkn lhkyc Ghkock lhkyctcdck tcdck ecmw ecmwcc scyc G`dt G`dthr……… hr………………... ………......... ........... ........... ............ ........... ........... ......... ... thicm lhkhrc lhk hrckod kodck ck mci-mc mci-mcii gn ctc ctcss shf shfcrc crc ehk ehkcr cr gck jhics jhics gck lhl lhlehr ehrndc ndck k dhs dhshl hlpct pctck ck ukt uktud  ud   ehrtckyc gck/ctcu ehrgnsdusn

Wckgctckock

Ghkock nkn lhkyctcdck ecmwc scyc/dhiucroc Wckgctckock  pcsnhk ………………………………………….. thicm lhkhrnlc nkb`rlcsn shecoc she cocnlc nlckc kc gn ctc ctcss yck ycko o scy scycc ehr ehrnn tck tckgc/ gc/pcr pcrcb cb gn d`i d`i`l `l dck dckck ckkyc kyc shrtc shrtc thicm thicm gne gnehrn hrn dhshlpctck uktud ehrtckyc/ehrgnsdusn, gck thicm lhlcmclnkyc * Enic pcsnhk tngcd d`lphthk ctcu tngcd lcu lhkhrnlc nkb`rlcsn, lcdc phkhrnlc nkb`rlcsn cgcicm wcin ctcu dhiucroc thrghdct

Dhthrckock *): F`rht scicm sctu