SOP 1000.02, 1601.00

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Request for Therapeutic Phlebotomy

Important Information:
With the exception of approved hemochromatosis donors, therapeutic patients will only be drawn on Tuesdays, Wednesdays and Thursdays. Orders must be submitted (faxed) 72 hours prior to the first collection to allow time for review, Medical Director approval and data entry. Incomplete or illegible orders will not be accepted.
Patient Information
Full Name: / Date of Birth:
Address: / Telephone #:
SSN: XXX – XX – / (Last 4 digits only)

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SOP 1000.02, 1601.00

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Click “Drop Down” to select the diagnosis, or write it in below (no diagnosis codes please):

Diagnosis / Drop Down:
Patient History / Does this patient have any medical contraindications for this procedure?
No Yes (If yes, explain below.)
Minimum Hematocrit for Phlebotomy / 32% (minimum) / Prior to each phlebotomy, the hematocrit will be measured.
We do not perform CBC or ferritin testing.
Other:
Frequency / Discuss desired frequency with your patient.
Expiration / Order valid for 2 years from the date it is signed.
Physician Information
I request the above patient have a therapeutic phlebotomy of approximately 500 mL performed.
Physician’s Signature: / Date:
Printed Name: / Telephone #:
Address: / Fax #:

FAX COMPLETED REQUEST TO 713-790-1782 at least 72 hours prior to donation

Please call (713) 791-6608 with questions. To download this form visit www.giveblood.org.

OFFICE USE ONLY
Deferral entry required? Yes No / Reason:
Deferral entry (if required), initials/date:
SafeTrace ID: / MD Approval/Date:
Comments:

GC2400 v3 Commit for Life.®