Fillable Printable Parental Consent Blood Donation - California
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
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.
