Hospitals & Services
The decision to undertake a procedure to administer blood or blood product to a patient who is unable to provide consent or for whom there is no legal representative is ultimately the responsibility of the doctors caring for the patient. However, it is the Canterbury District Health Board's policy to consult, where practical, members of the patient's family, significant others and/or anyone else with a legitimate interest in the care of the patient, in order to help determine what the patient's wishes might be.
I (Doctors name)_____________(print) (Designation) ________________hereby certify that the Condition of (patients name) _________________________(print) was such that consent could not be obtained prior to the procedure of: ________________________________________________Which I further certify is, in my opinion, in her/his best interests.In reaching this opinion I have taken into account information provided to me by others interested in her/his welfare, the signature of one of whom appears below as witness.
In reaching this opinion, I have consulted with colleagues, the signature of one whom appears below as witness.SIGNED:___________________________ DATE: _______________ TIME: _____________________SIGNED: __________________________ DATE: _______________ TIME: _____________________NAME OF WITNESS: _____________________(print) (Relationship/Designation) ________________