Patient Details

Hospital Ward Patient Status Priority

Patient History Indication for Transfusion. Include indication code (see reverse). Transfusion History Requesting Medical Officer Signature

Test Required (see reverse)

Fresh Products Relevant Lab Value Special Requirements Maternal Details for patients under 4 months age Other Products (see reverse) Person Witnessing Collection to sign

Person Collecting Blood - must sign

Sample Requirements Red Cell Indications Dose Guidelines

Platelet Indications

Fresh Frozen Plasma Indications

Cryoprecipitate Indications

Blood Components and Products

Transfusion Tests list

This third page is the patients copy

NOTE: All details written on the front page will be visible on this page. This includes the Clinical History and Indications .