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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:
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.
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):
FOR Iron unloading (Hemochromatosis)
HCT will be performed before each phlebotomy. No CBC or ferritin testing provided
500 +/- 50 mL)
Required: One time ONLY Or Every week(s)
Hold collections after # of collections - Request will expire once filled
Does your patient have any medical contraindications or risks for phlebotomy?
No Yes (If yes, explain)
Physician Information (all fields are mandatory):
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.
Deferral entry required? Yes No
Deferral entry (if required), initials/date:
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