SPECIAL REQUEST ORDER FORM (RBC)
All Orders must be faxed [Section 1 to be filled out by Hospital /Section 2 to be filled out by CBS.]
Site:
B.C. and Yukon
Fax Number:
(604) 879-6669
Phone Number:
(604) 876-7219
Section 1: To Be Filled Out By Hospital
Hospital/Customer:
City/Town:
Date:
Routine □
Delivery Priority:
Time:
Requested By:
ASAP □
*STAT □
[*STAT orders must be faxed and phoned]
Delivery Mode:
Comments:
PATIENT:
Birth Date:
Initials
Antibodies Identified:
(ccyy-mm-dd)
Number of Units Required:
ABO/Rh:
Antigen Neg. Phenotype Required:
(Circle)
C E c
e S
Other Antigens Required:
Will you accept ABO compatible units if group ordered is not available?
If no, why?
Are you able to re-test with commercial antisera for all phenotype(s) requested?
s K Fya
□
Yes
□
No
□
Yes
□
No
Fyb
Jka
Jkb
If no, indicate which antigens you are unable to test for:
ADDITIONAL UNIT PREPARATION OR REQUIREMENTS (check all that apply)
□Irradiated
□Washed
□IgA Deficient Recipient
□To be transfused on:
□Anti-CMV Negative
□Other - Specify
□Less than
□Deglycerolized
□For surgery on:
days old
□For Stock Only
Section 2: For CBS Use Only – Donation Numbers of Acceptable Units (if applicable)
CBS Comments:
Order to Be Filled:
(Amount)
(ABO/Rh)
(Product Type)
(Progesa Order#)
1000103465
2012-11-07