FORM FRM33/3
Effective: 19/01/16
Request for Recovery of Frozen
Allogeneic/Autologous Units
NATIONAL FROZEN BLOOD BANK
NHS Blood and Transplant, 14 Estuary Banks, Speke, Liverpool. L24 8RB
Tel: 0151 268 (5)7165, (0151 268 (5)7170 after 5pm and weekends) Fax: 0151 268 (5)7173
1.
Requesting Blood Centre:
Requesting Date:
Requested by (name):
Designation:
Signature:
Out of hours Tel no:
Featurenet ext:
2.
Units to be recovered from: General Stock
3.
Patient’s name:
Patient’s DOB:
Hospital where patient is being treated:
Hospital PULSE code:
Hospital no:
NBS Ref Lab no:
ABO:
Rh phenotype:
Other phenotype/s:
Clinical condition:
Antibodies:
Has frozen blood been used before: Yes/No
4.
Details of units required ABO:
Rh phenotype:
Other phenotype/s:
Number of units:
Has request been telephoned?
5.
Date and time blood required -
Yes/No
Date:
Date:
Time:
Time:
Institution and address to which blood should be sent:
6.
Authorising NHSBT Consultant
Name:
7.
Signature:
For NFBB use
Request received by signature:
Was request fulfilled?
Yes/No
Date:
Time:
If yes, number of units:…………………
From (delete as required): General Stock/Reserved/Autologous
If no, reason:…………………………………………………………….
Were wet units provided?
Yes/No
If yes, how many? …………From where?.......................................................................................................
Donation Nos:…………………………………………………………………………………………………………..
Date and time units despatched -
Date:
Time:
Signed:
(Template Version 07/10/08)
Cross-Referenced in Primary Document: SOP158
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