ORDERING PHYSICIAN: Fax completed form (page 1 and 2) to outpatient booking at applicable site.
99 - 01 - 30719 - 0 Revised 10/2013
Outpatient
Blood Product
Booking Request
)
Name: _____________________________________________________
DOB: ______________________________________________________
PHN: ______________________________________________________
Pt. Phone #: ________________________________________________
(Use Out Patient IVIG Approval/Booking Request for IVIG)
Page 1 of 2
Diagnosis:___________________________________________________________________________
Allergies:________________________________________________________________ None known
Previous transfusion reaction? No Yes, describe
Antibiotic resistant organisms: None Unknown MRSA VRE ESBL
PICC/SVAD: No Yes, location________________________________________________________
Medication
Medication
Medication
Relevant History:
For transfusion-dependant patient with recurring appointments requested:
Usual day(s) of week transfusion surveillance samples (hematology panel, hold for G&S) drawn:
Mon Tue Wed Thu Fri Sat Sun
Booking Information: Preferred hospital location for infusion(s):_______________________
Patient not available: Mon Tue Wed Thu Fri Sat Sun
Patient absences:_____________________________________________________________
Consent for Transfusion of Blood Products:
Accompanies this form To be signed in outpatient nursing unit
* Physician must have reviewed benefits, risks and alternatives of receiving a blood product with
patient.
Urgency:
Urgent (within 72 hours) Semi-Urgent (within 1 week) Other (Specify date____________)
MSP Practitioner #
Physician signature
Date of request
LAB USE ONLY: Does patient have an antibody card? No Yes, copy sent to TML
Print Form
ORDERING PHYSICIAN: Fax completed form (page 1 and 2) to outpatient booking at applicable site.
99 - 01 - 30719 - 0 Revised 10/2013
Outpatient
Blood Product
Booking Request
)
Name: _____________________________________________________
DOB: ______________________________________________________
PHN: ______________________________________________________
Pt. Phone #: ________________________________________________
RED BLOOD CELLS (RBC’S)
Clinical indication (required):
Hgb less than 70 g/L
Hgb 70-90 g/L with:
Cardiovascular compromise
Bone marrow failure disorder
On chemotherapy
Other, specify:_______________________
Special requirement:
CMV negative
Irradiated
Other, specify__________________________
Single transfusion request:
Adult: _________ unit(s) RBC’s
Pediatric: _________ mL RBC’s
Hgb:_________ g/L, Date drawn:_____________ (must be within 7 days)
Please arrange for sample collection for blood group and antibody screen within 3 days of booked date
of transfusion.
PLATELETS
Clinical indication (required):
Platelet count less than 10 X 10
9
/L
Bone marrow failure disorder
On chemotherapy
Other, specify_______________________
Special requirement:
CMV negative
Irradiated
Other, specify
Request:
Adult I unit Platelets
Pediatric: ______ mL Platelets
Platelet count: _________ X10
9
/L, Date drawn: _____________ (must be within 48 hours)
RECURRING APPOINTMENTS (Transfusion-dependant patients only. Maximum duration 3 months.)
Reserve MAP/MDC bed for possible transfusion every ______ weeks
If Hgb less than or equal to _________ g/L, give ______ unit(s) RBC’s
If Hgb greater than _________ g/L, but less than or equal to _________ g/L give ______ unit(s) RBC’s
If platelet count less than or equal to _________ X10
9
/L, give 1 unit Platelets
Must complete “Clinical indication and “Special requirement for applicable blood product(s).
OTHER BLOOD PRODUCT (NOTE: Use Out Patient IVIG Approval/Booking Request for IVIG bookings)
Clinical indication (required):
__________________________________________
Type _____________ Amount ___________
SUPPLEMENTAL TRANSFUSION ORDERS
Physician last and first name, middle initial
Physician phone
MSP Practitioner #
Physician signature
Physician fax
Date of request
BOOKING PERSONNEL
Location of transfusions:
Date/
Time
Date/
Time
Date/
Time
Date/
Time
Date/
Time
Date/
Time
Date/
Time
Date/
Time
Date/
Time
Date/
Time
Date/
Time
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