Fillable Request for Autologous / Directed Donations (Gulf Coast Regional Blood Center)

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Request for Autologous / Directed Donations (Gulf Coast Regional Blood Center)

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SOP 1000.08
Page 1 of 1
GC2417 v3 Commit for Life.®
Request for Autologous / Directed Donations
PATIENT INFORMATION A
LL INFO MUST MATCH HOSPITAL RECORDS
Date
Last First Middle Initial
Birth Date Last 4 Digits of SS#___ ___ ___ ___
Gender Male
Address Female
City State Zip
Daytime Phone Evening Phone
HOSPITAL INFORMATION - DO NOT ABBREVIATE
Scheduled Date of Usage Medical Record Number (if applicable)
Patient’s Blood Type Type of Procedure/Diagnosis
Facility Name City/State
ORDERING PHYSICIAN INFORMATION
Last First
Address Phone #
City Zip Fax #
AUTOLOGOUS
Whole Blood
Red Blood Cells
Plasma
Other, please specify:
By signing below, Physician confirms the patient
will be able to tolerate the Autologous blood
donation procedure(s) and does not have any
medical contraindications for blood donations.
Please ensure the risks and benefits of Autologous
donations and/or transfusions have been discussed
with the patient.
DIRECTED
CMV Negative
Red Blood Cells
Platelets
Plasma
Apheresis Platelets
Other, please specify:
Date:
FAX COMPLETED REQUEST AND AN ADDITONAL SET OF DEMOGRAPHICS TO
713-790-1782
Please call (713) 791-6608 for questions or to download this form check web site www.giveblood.org.
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Request for Autologous Directed Donations (Gulf Coast Regional Blood Center)

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Completed 28 May 2021

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