Get Request For Autologous Donor Blood Components - Lstream

This guide provides a comprehensive, step-by-step approach to filling out the REQUEST FOR AUTOLOGOUS DONOR BLOOD COMPONENTS - Lstream online. By following these instructions, users can ensure that all necessary information is accurately provided to facilitate the donation process.

Follow the steps to complete the online form effectively.

1. Click ‘Get Form’ button to access and open the form in your designated editor.
2. Begin by filling in the patient’s information. Include their date of birth, social security number or medical record number, and fully print their last name, first name, and middle initial if applicable.
3. Provide the patient’s address and phone numbers. Ensure to list the home, work, and cell numbers separately for clarity.
4. Detail the surgical procedure the patient is undergoing, along with their ABO-Rh blood type if known.
5. Include contact information for a person other than the patient. This person should be listed by name, relationship to the patient, hospital affiliation, and their phone number.
6. Specify the surgery or transfusion date along with the location's address and phone number.
7. Indicate the components requested by selecting from the provided options, ensuring to note the number of components needed.
8. Fill in the physician’s details such as name, address, phone number, email, and fax.
9. Read and acknowledge the section regarding the residual viral risk and the risks involved in autologous donation.
10. The physician must provide their consent by signing and dating the form. Ensure the signature is authorized to avoid any delays.
11. After completing all sections, review the form for legibility and accuracy. Once confirmed, save your changes, and choose to download, print, or share the form as needed.

Complete your REQUEST FOR AUTOLOGOUS DONOR BLOOD COMPONENTS - Lstream online now to ensure timely processing.