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THERAPEUTIC PHLEBOTOMY PHYSICIAN ORDER

All information MUST be filled out in its entirety to be considered valid.

Please fax completed form to (405) 297-5598 ATTENTION: Special Donation Coordinator. For Questions please call (405)297-5597

PATIENT INFORMATION

Patient Name:

D.O.B: (mm.dd.yyyy)

Mailing Address:

Gender

Male     Female

City:

State:

Zip Code:

Phone Number:
(xxx)xxx-xxxx

Alternate Number:
(xxx)xxx-xxxx


All orders are for whole blood collection procedures; approximately 500 mL of blood will be removed from the patient with each collection.

  1.  Reason for Therapeutic Draw (Mark all that apply):

     Secondary Polycythemia due to:

     Porphyria                   Polycythemia Vera (slow-growing blood cancer)

    Erythrocytosis due to:             

    Other Reason (Explain) :        

  2. Frequency (mark ONE of the following):

      One time Whole Blood Phlebotomy Procedure

      Weekly

      Every 2 Weeks                

      Every 4 Weeks

      Every 8 Weeks  

    3. ERROR MESSAGE: ALL REQUIRED FIELDS ARE NOT COMPLETE!!

    Please complete the areas highlighted red before attempting to print. Incomplete forms will not be accepted.

    *Hematocrit Target =

*This is the minimum HCT the medical care provider is authorizing phlebotomy. HCT must be greater than or equal to 33%. Some donor centers perform Hgb testing.
At these locations minimum Hgb will be calculated as HCT รท 3.
NOTE: The blood institute does NOT perform ferritin levels and cannot perform phlebotomy for specific ferritin levels.


Ordering Medical Care Provider Signature:


Date:(mm.dd.yyyy)

Printed Ordering Medical Care Provider Name:

Office Phone:
(xxx)xxx-xxxx


Fax:
(xxx)xxx-xxxx



ABI/OBI/TBI/CMBC Personnel Only

BECS Patient ID:


Date order received:


Tech ID:


Date deferral entered:


Tech ID:


Date order expires:


Date order entered into BECS:


Tech ID:


Comment Section:


Reviewed by:


Date Reviewed:


Facility Name: Sylvan N. Goldman 1001 N. Lincoln, Oklahoma City, Oklahoma 73104.

The official copy of blood bank documentation is the electronic copy on file with the local area network. The official copy of records created from forms is paper unless designated otherwise.

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