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[Hospital Name][HospitalAddress] |
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| REQUEST FOR BLOOD AND BLOOD COMPONENT |
| Requirement | : | [Requirement] | Date | : | [RequestDate] | |||||
| Patient No | : | [Ptno] | IP No | : | [IP #] | |||||
| Name | : | [Name] | Sex | : | [Sex] | |||||
| Address | : | [Address1][Address2] | Consultant | : | [Consultant] | |||||
| Age | : | [Age] | Room & Bed No. | : | [RBNo] | |||||
| Indication for tranfusion | : | [Indication] | Hb | : | [HB] |
| Blood Group(ABO) | : | [Bgroup] | Rh | : | [RH] |
| Previous Transfusions | : | [PreTranfuse] | Any Reactions | : | [TransfuseReactions] |
| Previous Pregnancies | : | [PrePregnant] | |||
| Request | : | [RequestType] | Remarks | : | [Remarks] |
| Diagnosis and brief clinical note | : | [Diagnosis] | |||
| Does the patient has any blood born disease | : | [BloodBorn][BloodBornRemarks] | |||
| Required | : | [BloodRequirement] | |||
| Has children (if any) been affected with HDNB (Haemolytic Disease of New Born) : [HDNB] |
| Any still births of miscarriages? : [StillBirth] |
| Componets with required units | : | [ComponentsRequired] |
| User Name | : | [UserName] | Printed Time | : | [PrintDate] |