Republic of the Philippines

PROVINCE OF BOHOL
Garcia Memorial Provincial Hospital
San Jose, Talibon, Bohol
Fax & Tel No.038-5155081
e-mail gmph.bohol2012@gmail.com
PHILHEALTH ACCREDITED HEALTHCARE PROVIDER

PHILIPPINE NATIONAL VOLUNTARY BLOOD SERVICES PROGRAM

(REGION) REGIONAL BLOOD SERICES NETWORK: NCR
(ZONE): _______________________________
BLOOD REQUEST FORM
(For Pediatric)

Date: ________________ Hospital: ____________________

Name of Patient’s: _________________________________________________________ Age: ______ Sex_______

Surname First name Middle name
Amending Physician: ___________________________ Ward _________ Room #________ Hosp. # _________
Clinical Diagnosis: ______________________________________________________________________________
Patient’s Blood Type ___________________ Rh _____________
History of Previous Transfusion: When ____________________
Where ____________________
Type of Request ( ) ROUTINE ( ) STAT
Check Components Needed and Indication for Transfusion:

( ) Whole Blood

For Exchange Transfusion :

( ) Hyperbilirubinemia in infant with indirect bilirubin of 20 mg/dl in first week of life.
( ) Hyperbilirubinemia with prematurity and / or other concomitant illness to include one or more
of the following: Prenatal asphyxia, acidosis, prolonged, hypoxemia, hypothermia, sepsis, and
hemolysis.
( ) Others (Specify) _________________________________________

( ) Packed Red Cells / ( ) Washed Red Cells

( ) Signs and symptoms of anemia (e.g. pallor etc.)

( ) Hypovolemia from acute blood loss with signs of shock or anticipated blood loss of > 10%
( ) Candidates for Major Surgery and hematocrit < 30% (Nocturnal < 35 %)
( ) Hypertransfusion for chronic – hemolytic anemias; (Thalassemia)
( ) Hemoglobin 13 gm (Hct. 40) and assisted ventilation.
( ) Anemia with HGB < 8 gm / dl or Hct < 25%
( ) Blood Volume reduction of 10 ml / kg and with HCT < 45% in newborn less than 4 months of
age
( ) Pulmonary disease or congenial heart disease with less hct 40% - 45%
( ) Others (Specify) _____________________________________________
 ( ) Platelet Concentrate

( ) Active bleeding and thrombocytopenia < 50,000 /L or al risk for intracranial hemorrhage.
( ) Active bleeding and qualitative defect
( ) Prophylaxis for severe thrombocytopenia < 20, 000 /L or associated qualitative defect.
( ) Schedule invasive procedure and thrombocytopenia < 70, 000 /L or associated qualitative
defect.
( ) Others (Specify) _____________________________________________

( ) Fresh Frozen Plasma

( ) Significant multiple coagulation factor deficiency or acquired factor deficiency

(e.g. dengue, shock syndrome )
( ) Significant congenital factor deficiency
( ) Anti- thrombin III deficiency
( ) Bleeding in exchange transfusion or massive transfusion ( > 1 Blood Volume )

( ) Cryoprecipitate

( ) Factor VIII Deficiency (Hemophilia A )

( ) Von Willebrands Disease
( ) Disseminated Intravascular Coagulation
( ) Uremia with active bleeding or schedule invasive procedure
( ) Others (Specify) _______________________________________________

No. of units needed: _______________________________

Type of Crossmatching No. of Donors Provided :

( ) Saline Phase only Screened : ____________

( ) Saline, Albumin Phase Unscreened: ____________
( ) Saline, Albumin, Globulin Phase Total : ____________

Others: ________________________________

Remarks: _____________________________________________________________________________________

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REQUESTING PHYSICIAN

Received by: ________________________________ Date/ Time _________________

Extracted by: ________________________________ Date/ Time _________________