ANTHONY NOLAN
2 Heathgate Place
75-87 Agincourt Road
London NW3 2NU
www.anthonynolan.org
T:+ (44) 0303 303 0303
F: +(44) 0207 284 8226
Emergency: + (44) 07710 599161
E: donorprovision@anthonynolan.org
Registered charity number
803716/SC038827
PRESCRIPTION FOR BONE MARROW COLLECTION
(To be completed by the transplant centre)
Recipient Initials:
Recipient ID:
(assigned by recipient’s TC/registry)
Recipient ID:
Recipient ID:
(assigned by Anthony Nolan)
(assigned by donor’s registry)
Donor registry:
Donor ID number:
PRE-COLLECTION PERIPHERAL BLOOD SAMPLES (maximum 100 mls):
mls. EDTA
mls. ACD
mls. Heparin
mls. no anticoagulant
Other, please specify:
Samples to be shipped to:
Name:
Address:
Product to be delivered to:
Name:
Address:
NOTE: This blood will be drawn at the donor
medical unless otherwise requested.
Phone no:
Phone no:
Fax no:
After hours number:
Email:
Fax no:
BONE MARROW COLLECTION
NUCLEATED CELLS PER KG (UNCORRECTED)
X 10^8/kg
x recipient weight (kg)
kg
= total nucleated cells for recipient (uncorrected)
X 10^8
+ nucleated cells for quality assurance
X 10^8
= Total nucleated cells
X 10^8
Ethics Approval Date (if appropriate)
(day/month/year)
Anticoagulant:
Media for marrow transportation:
Packing instructions for transport: (i.e. temperature, special requirements, etc)
PERIPHERAL BLOOD SAMPLES TO BE COLLECTED AT TIME OF HARVEST(maximum 100 mls):
mls. EDTA
mls. ACD
mls. Heparin
mls. no anticoagulant
Marrow:
Additional comments:
Transplant physician:
Signature:
Date:
(day/month/year)
DOC1103
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