FEDERAL MINISTRY OF HEALTH

TRANSFUSION REQUEST FORM

HF Name
Patient’s name Age /DOB Sex
Ward MRN
Address Wored Kebele House
a Number
Diagnosis
Blood group if Known
History of previous
transfusions
History of previous
pregnancies

Reason for Transfusion

Number of Units Required

Product Number of units Date Required* Time
Whole Blood
Packed Red Cells
Platelets
Fresh frozen Plasma

Name of Requesting Signature

physician
Date of request

Units Cross Matched

Unit Number Immediate Spin Complete X match (coomb’s)

Name of Technician Signature

Date
*Indicate if emergency