FORM FRM5122/1.1
Effective: 21/01/15
Therapeutic Apheresis Services
Request for Therapeutic Plasma Exchange
Patient Demographics
Last Name
First Name(s)
NHS Number
D.O.B
Hospital Number
Patient Contact Number
Hospital
Ward /Outpatient
Consultant Name
Consultant Contact Number
Ward Contact Number
Diagnosis
Patient diagnosis:
What is the indication for plasma exchange?
What is the aim of plasma exchange?
How will the effectiveness of plasma exchange be monitored?
Treatment Requested
Number of plasma exchanges requested:
Over what time period:
Preferred date of first procedure:
Is the patient suitable for treatment on the apheresis unit?
Yes
No
If no, where will the procedures take place?
Height
Weight
Replacement Fluids
Do you authorise NHSBT to manage patient fluids?
Yes
No
Human Albumin Solution (5% - 4.5%) and saline are standard
replacement fluid except for TTP when Octaplas is used. Does this
patient require different fluids?
Yes
No
If yes, please
specify:
(Template Version 01/11/13)
Cross-Referenced in Primary Document: MPD583
Page 1 of 2
FORM FRM5122/1.1
Effective: 21/01/15
Therapeutic Apheresis Services
Request for Therapeutic Plasma Exchange
Other Information
Does the patient have any significant co-morbidities which would require modification of the procedure
(e.g. cardiovascular, renal or bleeding diathesis)?
Medication:
Does the patient have any allergies?
Yes
No
(If yes, please specify)
A full blood count is included in the treatment package price. Please provide forms / requests for any
additional blood tests required
Please provide relevant blood test / laboratory results
Vascular Access
Are peripheral veins adequate for apheresis? Yes
No
Is an apheresis central line already in place? Yes
No
Will an apheresis central line be inserted? Yes
No
(If yes, please advise date of insertion)
Detail of member of staff completing this form
Name:
Grade:
Date:
Signature:
Phone Number
Email address:
(*To ensure confidentiality please ensure an nhs.net email address is provided)
For Use by NHS Blood and Transplant
Has the referral been accepted?
Yes
No
Comments:
(Template Version 01/11/13)
Cross-Referenced in Primary Document: MPD583
Page 2 of 2