Fillable Printable Parental Consent Blood Donation - California

Parental Consent Blood Donation - California

Community Hospital of the Monterey Peninsula Document Number: BDQ 301.02aD v2

Monterey, CA 93940 Effective Date: 01/22/09

Blood Center

Parental Consent Blood Donation

This form is required for blood donation by persons 16 years of age who have not yet

reached the age of legal majority as defined by the laws of the state of California.

PLEASE HAVE A PARENT OR GUARDIAN COMPLETE THIS FORM IN BLACK INK

I do hereby give my consent for (donor’s full name), __________________________, at his

or her discretion, to donate to Community Hospital of the Monterey Peninsula Blood Center

on (date)_____________________.

__________________________________________ _____________________

Signature of Parent or Guardian Date

Donor’s Age: Donor’s Date of Birth:

_______________________________________________________________________

Address

_________________________________________________________________________( )___________________________

City State Zip Phone

LAST MINUTE REMINDERS

Present this consent at the time of donation.

Bring a picture I.D. (driver’s license or student identification card).

Bring (or remember) your social security number.

Eat a good meal and drink plenty of water before and after giving blood.

Bring your friends to give blood too!

Community Hospital of the Monterey Peninsula Document Number: BDQ 301.02aD v2

Monterey, CA 93940 Effective Date: 01/22/09

Blood Center

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Information About Blood Donation

FAQ’s SPECIAL CIRCUMSTANCES

WHO CAN GIVE BLOOD? You must be at least 16 years

old and be in generally good health. 16‐year‐old

students must have a parent or guardian sign the

“Parental Consent for Blood Donation” form.

The following are potential limitations to your eligibility

to give blood:

HOW MUCH BLOOD DO THEY TAKE? You will give about

one pint of blood with each donation. For every 25

pounds of body weight, you have about two pints

of blood. Your body replenishes the lost fluids

within about 24 hours.

BODY PIERCING: A piercing is okay if it is preformed with

single use or disposable equipment in a professional

setting and is completely healed. Otherwise, wait one

year from the time of piercing.

IS GIVING BLOOD SCARY? It’s natural to feel a little

nervous about your first blood donation, but giving

blood is safe and easy!

HIV/AIDS: You cannot give if you are in a high‐risk group

for contracting HIV/AIDS.

IS GIVING BLOOD SAFE? Yes. Sterile, disposable needles

are used only once for each donation. The only

blood you are exposed to is your own.

PREGNANCY: You cannot donate during pregnancy.

Wait six weeks after recent pregnancy, regardless of

outcome or length.

HOW OFTEN SHOULD I GIVE BLOOD? You can give whole

blood as often as every eight weeks. And once you

give your first pint of blood and find out how easy

it is, why not become a regular blood donor?

COLD/FLU: You must be symptom‐free for at least

48 hours. Do not give blood if you have a fever, stomach

or body aches, chills , diarrhea or sore throat.

IS THE BLOOD SUPPLY SAFE? Confidential medical history

interviews and confidential testing for infectious

diseases ensure safety.

ACNE TREATMENT: Wait one month after taking

Accutane, Amnesteem, Claravis, or Sotret (isotretinoin).

CAN I FIND OUT MY BLOOD TYPE? Yes. After your first

blood donation we will mail you a card with your

blood type.

DIABETES: Acceptable if controlled by diet or

medication.

WON'T DONATION MAKE ME WEAK? The vast majority

of people will not feel any different because of the

donation. A very small percentage may experience

temporary dizziness, but some rest and fluids will

help you feel better quickly.

DRUGS/ALCOHOL: If you are addicted to drugs or alcohol

do not give blood.

CAN I GIVE IF I HAVE BEEN TURNED DOWN BEFORE? Most

reasons for which donors are deferred from

donating blood are temporary. For example, one

common reason for a deferral is a low iron level in

the blood, but iron levels fluctuate daily and are

affected by what you eat.

TATTOOS: Wait one year from time of procedure.