Fillable Request for Therapeutic Phlebotomy

Fill Online, Printable, Fillable, Blank Request for Therapeutic Phlebotomy Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Request for Therapeutic Phlebotomy

On average this form takes 9 minutes to complete

The Request for Therapeutic Phlebotomy form is 1 page long and contains:

  • 1 signature
  • 7 check-boxes
  • 30 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
SOP 1000.02
Page 1 of 1
GC2400 v13 Commit for Life.®
Request for Therapeutic Phlebotomy
FAX COMPLETED REQUEST TO (713) 790-1782
For questions, call (713) 791-6608. To download this form, visit https://www.giveblood.org/TherapeuticForm/
Incomplete forms are not accepted. Request expires two (2) years from date of signature.
Patient’s Full Legal Name:
Full Mailing Address:
Date of Birth:
Telephone #:
SSN (Last 4 digits only): XXX–XX–
All patients must call (713) 791-6608 to verify order receipt.
Please allow up to 3 business days for processing.
Diagnosis -
Reason for
Phlebotomy
Secondary Polycythemia due to D75.1
Testosterone Replacement Therapy
Secondary Polycythemia, other D75.1
Polycythemia Vera D45
Hereditary Hemochromatosis E83.110
Other Hemochromatosis E83.118
Other (Include both ICD-10 Code and Diagnosis):
Minimum
Hematocrit
for
Phlebotomy
FOR Polycythemia
FOR Iron unloading (Hemochromatosis)
45%
33% (minimum)
Other:
Other:
Frequency
(Whole Blood
500 +/- 50 mL)
Required: One time ONLY Or Every week(s)
Optional:
Hold collections after # of collections - Request will expire once filled
Patient
History
Does your patient have any medical contraindications or risks for phlebotomy?
No Yes (If yes, explain)
Physician Information (all fields are mandatory):
Physician’s Signature:
Date:
Printed Name:
Telephone #:
Full Mailing Address:
Fax #:
Therapeutic patients will only be drawn on Tuesdays, Wednesdays and Thursdays between 8:00 AM and 4:00 PM
unless they are approved testosterone replacement or hereditary hemochromatosis donors.
Blood Center USE ONLY
Deferral entry required? Yes No
Reason:
Deferral entry (if required), initials/date:
e-Delphyn ID:
MD/Designee Approval/Date:
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Request for Therapeutic Phlebotomy

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 28 April 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document