!!! EXTERNAL AUTOLOGOUS REQUEST FORM !!!

AUTOLOGOUS REQUEST FORM

Physician’s Request for Autologous Donation: F.DS.1600b

This request will be reviewed by our Special Donations Coordinator and/or Medical Director. If approved, we will call the patient to schedule their donation. All donations must be scheduled ahead of time to ensure accurate and timely service. We do not accept walk-ins. If this request is not approved, the ordering physician will be notified. Please allow up to 3 business days for completion of the approval process.

Section I Patient Information: To be Completed by Physician's Office

Patient's Last Name

Patient's First Name

Patient's Sex

Patient's D.O.B

MM/DD/YYYY

Patient Phone Number

Address I

Address II

City

State

ZipCode

Office Comments

Section II Physician's Order: To be Completed by Physician's Office

Transf / Surgery Date

No less than 3 days from today*

Number of Units

Intended Procedure

Collection Location

Select a Hospital

Hospital - Other

Process As

Leuko-reduce RBC Whole Blood

Please check any of the following medical problems that might adversely affect patient’s tolerance to blood donation:

Physician Printed Name

Office Phone Number