Official Maximum Privacy

Maximum Privacy: Encrypted Agent Info

Refuses all blood products and fractions. Agent contact information is encrypted — visible only with passcode. For patients prioritizing maximum confidentiality.

7 refused 3 accepted
bloodless.org

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 REFUSE
Immunoglobulins REFUSE
Clotting factors REFUSE
Cell salvage ACCEPT
Hemodilution ACCEPT
Heart-lung bypass ACCEPT

3. Special Instructions

I refuse all blood products and fractions. I accept autologous procedures with continuous circuit. This directive is encrypted for privacy. My healthcare agent's identity and contact information are available only to authorized persons with the passcode. In an emergency, scan the QR code on my wallet card and enter the passcode to access the full directive.

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?

Some patients need their Medical Directives to be highly confidential. This template defaults to encrypting the healthcare agent's information — it won't be visible on the QR scan landing page without the passcode. This is useful in situations where the patient's medical choices or social connections could expose them to discrimination or unwanted attention.

Blood choices breakdown

Primary Blood Components

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

Blood Fractions

Albumin REFUSE
Immunoglobulins REFUSE
Clotting factors REFUSE

Autologous Procedures

Cell salvage ACCEPT
Hemodilution ACCEPT
Heart-lung bypass ACCEPT

Suggested special instructions

I refuse all blood products and fractions. I accept autologous procedures with continuous circuit. This directive is encrypted for privacy. My healthcare agent's identity and contact information are available only to authorized persons with the passcode. In an emergency, scan the QR code on my wallet card and enter the passcode to access the full directive.

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