Official Surgery Prep

Elective Surgery: Bloodless Prep

Designed for planned surgeries. Refuses donor blood, accepts fractions and autologous procedures. Includes pre-surgical optimization instructions.

4 refused 6 accepted
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Durable Power of Attorney

Blood-Related Medical Decisions

I, [Your Name], born [Date of Birth], residing at [Your Address], being of sound mind, hereby declare:

1. Appointment of Healthcare Agent

I appoint [Agent Name] ([Relationship]) (phone: [Phone]) as my healthcare agent for all decisions relating to blood-based medical treatments.

If my agent is unable to serve, I appoint [Alternate Agent Name] (phone: [Phone]) as successor.

2. Blood-Related Directives

I hereby direct that the following blood products and procedures be handled as specified:

Whole blood transfusions REFUSE
Packed red blood cells REFUSE
Plasma REFUSE
Platelets REFUSE
Albumin ACCEPT
Immunoglobulins ACCEPT
Clotting factors ACCEPT
Cell salvage ACCEPT
Hemodilution ACCEPT
Heart-lung bypass ACCEPT

3. Special Instructions

I am preparing for elective surgery and request a bloodless surgical approach. Please initiate preoperative blood optimization: check hemoglobin levels, begin iron supplementation and/or EPO if indicated, and plan for cell salvage during surgery. I accept all blood fractions and autologous procedures. I refuse allogeneic whole blood and primary components. Please coordinate with my surgical team regarding blood management strategy.

Executed in [State], [Country].

Signature / date
Witness 1
Witness 2 / Notary
Generated by bloodless.org for informational purposes only. Not legal advice. Verify execution requirements in your jurisdiction before signing.

Why this configuration?

Elective surgery provides the advantage of time for preoperative optimization. This template focuses on the preparation phase — building hemoglobin levels before surgery, planning for cell salvage during the procedure, and having alternatives ready. The instructions specifically prompt the surgical team to coordinate blood management.

Blood choices breakdown

Primary Blood Components

Whole blood transfusions REFUSE
Packed red blood cells REFUSE
Plasma REFUSE
Platelets REFUSE

Blood Fractions

Albumin ACCEPT
Immunoglobulins ACCEPT
Clotting factors ACCEPT

Autologous Procedures

Cell salvage ACCEPT
Hemodilution ACCEPT
Heart-lung bypass ACCEPT

Suggested special instructions

I am preparing for elective surgery and request a bloodless surgical approach. Please initiate preoperative blood optimization: check hemoglobin levels, begin iron supplementation and/or EPO if indicated, and plan for cell salvage during surgery. I accept all blood fractions and autologous procedures. I refuse allogeneic whole blood and primary components. Please coordinate with my surgical team regarding blood management strategy.

Copies blood choices and instructions into the editor. All personal fields start blank.