Republic of the Philippines

Province of Laguna
LPH – GENERAL CAILLES MEMORIAL DISTRICT HOSPITAL
Tavera Street, Pakil, Laguna * Telephone Nos.: (049) 557- 0213 / 0214 / 0215
Email Addresses: caillesjuan@yahoo.com.ph/ lph.gcmdh@laguna.gov.ph
ACCREDITED HEALTHCARE PROVIDER

REQUEST FOR BLOOD AND COMPATIBILITY TESTING

CASE NUMBER: __________________ WARD/RM NUMBER: ________ AGE/SEX: ___________ DATE/TIME: _______________________
FIRST NAME: _____________________________ MIDDLE NAME: ______________________ LAST NAME: ____________________________
BIRTHDATE: _____________________________________ REQUESTING PHYSICIAN: _______________________________________________
DIAGNOSIS: ________________________________________________________________________________________________________________
MEDICAL HISTORY: _________________________________________________________________________________________________________

Blood Component Needed: ____________ Patient’s Blood Type: ________ Donor’s Blood Type: ________ Blood Bank: _____
Serial Number: _________________ Collection Date: _____________ Expiry Date: ________ Segment Number: ___________

Routine Transfusion (Yes/No) __________ Method: Complete Crossmatch (Gel Card/Modified Coombs: 3 Phases) at least 2 hours

Emergency Transfusion (Yes/No): _____________ Date/Time Needed: _______________ Method: Slide Method, Saline Phase Only

Number of Units for Testing: __________ Date/Time Needed: ____________ For Modification (Yes/No) : ______________________

REQUEST / CONSENT FOR EMERGENCY TRANSFUSION

Because of the extreme need of blood for transfusion, I ______________________ hereby direct the blood bank to release the following:
( ) Group “O” blood UNCROSSMATCHED
( ) ABO Type- specific Blood UNCROSSMATCHED
( ) ABO Type-specific Blood CROSSMATCHED using slide method ONLY
( ) CROSSMATCHED BLOOD using tube method: saline phase ONLY
( ) CROSSMATCHED BLOOD using tube method: albumin phase ONLY
Justification for Emergency release of blood unit/s: ___________________________________________________________________________
____________________________________ _____________________________________
Attending Physician Resident On-duty
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Republic of the Philippines
Province of Laguna
LPH – GENERAL CAILLES MEMORIAL DISTRICT HOSPITAL
Tavera Street, Pakil, Laguna * Telephone Nos.: (049) 557- 0213 / 0214 / 0215
Email Addresses: caillesjuan@yahoo.com.ph/ lph.gcmdh@laguna.gov.ph
ACCREDITED HEALTHCARE PROVIDER

REQUEST FOR BLOOD AND COMPATIBILITY TESTING

CASE NUMBER: __________________ WARD/RM NUMBER: ________ AGE/SEX: ___________ DATE/TIME: _______________________
FIRST NAME: _____________________________ MIDDLE NAME: ______________________ LAST NAME: ____________________________
BIRTHDATE: _____________________________________ REQUESTING PHYSICIAN: _______________________________________________
DIAGNOSIS: ________________________________________________________________________________________________________________
MEDICAL HISTORY: _________________________________________________________________________________________________________

Blood Component Needed: ____________ Patient’s Blood Type: ________ Donor’s Blood Type: ________ Blood Bank: _____
Serial Number: _________________ Collection Date: _____________ Expiry Date: ________ Segment Number: ___________

Routine Transfusion (Yes/No) __________ Method: Complete Crossmatch (Gel Card/Modified Coombs: 3 Phases) at least 2 hours

Emergency Transfusion (Yes/No): _____________ Date/Time Needed: _______________ Method: Slide Method, Saline Phase Only

Number of Unites for Testing: __________ Date/Time Needed: ____________ For Modification (Yes/No) : ______________________

REQUEST / CONSENT FOR EMERGENCY TRANSFUSION

Because of the extreme need of blood for transfusion, I ______________________ hereby direct the blood bank to release the following:
( ) Group “O” blood UNCROSSMATCHED
( ) ABO Type- specific Blood UNCROSSMATCHED
( ) ABO Type-specific Blood CROSSMATCHED using slide method ONLY
( ) CROSSMATCHED BLOOD using tube method: saline phase ONLY
( ) CROSSMATCHED BLOOD using tube method: albumin phase ONLY
Justification for Emergency release of blood unit/s: ___________________________________________________________________________
____________________________________ _____________________________________
Attending Physician Resident On-duty