You are on page 1of 3

Blood issuing form.

Time of sample collection---------:-----------Hrs

Sample type.(WB/SERUM/PLASMA).

Sample collected by------------------------------------.

Condition of the sample-------------------------------.

Name of patient--------------------------------------------------------

Age---------------yrs

IP No---------------

Ward--------------------

Sex------------------------

Hb-------------------g/dl.

Patient’s Blood group------------------

Donor Blood group------------------------

Donor Number-------------------------------

Pilot Number------------------------------------

Expiry Date-------------------------------

Cross match Results-----------------------------

Cross matched by-----------------------------sign--------------------Date----------------


Reviewed by------------------------------------sign----------------------Date-------------------.

Issued by---------------------------------------sign-----------------------Date-------------------

Received by--------------------------------------sign----------------------Date--------------------.

You might also like