LIFE CARE HOSPITAL

BOOTY MOD, RANCHI- 834009

REQUISITION FOR SUPPLY OF BLOOD/ BLOOD COMPONENTS

To,

Blood Bank,

SL. NO. : ROUTINE EMERGENCY

PATIENT NAME:………………………………………………………………………………………………………………………………………

HOSPITAL NAME: AGE: SEX: WARD NO. :

OP/IP NO./Reg. no. Bed No.

Blood Group: Rh: Hemoglobin gms/dl

Name of medical officer:

Contact No. of treating Doctor:

Diagnosis…………………………………………………………Reason for BT………………………………………………………………

Whether Blood Transfused Earlier Yes/No…………………………………………………………………………………………….

If Yes any adverse transfusion reaction? Yes/No…………………………………………………………………………………..

Obstetrical History…………………………………………………………………………………………………………………………………

(For Female Patient’ s)

Nature of B.T( Please Put a tick mark)

Whole blood Packed cell Platelet Fresh frozen Factor viii

cryoprecipitate
plazma
No. of units required………………………………………………………………………………………………………………………………..

Platelet Count(in case of demand for platelet concentrate)…………………………………………………………………….

Date of Transfusion………………………………………..

Time of Transfusion………………………………………..

Signature of Phlebotomist: Signature of MO

Name: Name:

MCI Reg. No.:

FOR BLOOD BANK USE ONLY

Blood Requisition form Received By:…………………………………………..Date/Time:…………………………………….

Blood Group Of Patient:…………………………………………………..

FORWARD BLOOD GROUPING REVERSE GROUPING

A A1 B AB D ABO A B O
Rh & Rh
FINAL SERUM/PLASMA GROUPING

D1(IGM) D2(IgG) Weak

D D3

PLEASE NOTE: Send the patient sample (2cc clotted+EDTA blood) for cross – matching, labeled with
Name, Age, IP/OP No., Hospital Name with signature of the phlebotomist on sample vial.

UNLABELLED BLOOD SAMPLES WILL NOT BE ACCEPTED