Blood Bank Request Form

Physician - Blood Bank Request Form **BLOOD BANK REQUEST FORM** **Patient Details:** Patient Name: John Smith Date of Birth: 15/03/1978 Hospital ID: HOS1234567 **Requesting Physician Details:** Requesting Physician: Dr. Sarah Evans Department: General Surgery Contact Number: 020 7946 0123 **Reason for Request:** Diagnosis: Acute Appendicitis Clinical Symptoms/History: Right lower quadrant pain for 24 hours, fever, elevated white blood cell count. **Type of Blood Product Required:** * **Packed Red Blood Cells (PRBCs):** Yes * Number of Units: 2 * Urgency: STAT * **Fresh Frozen Plasma (FFP):** No * **Platelets:** No * **Cryoprecipitate:** No * **Other (specify):** N/A **Pre-Transfusion Testing:** ABO/Rh Type: A Positive Antibody Screen: Negative Crossmatch required: Yes Date/Time of Sample Collection: 1 November 2024, 08:30 **Transfusion History:** Previous Transfusion Reactions: No Details of Previous Transfusions: Received 1 unit PRBCs in 2018 post-op for knee surgery. **Special Requirements (if any):** Irradiated: No Leukocyte-reduced: Yes CMV negative: No Other: N/A **Consent:** Patient consent obtained for transfusion: Yes **Date and Time of Request:** 1 November 2024, 09:15 **Authorised By:** Dr. Sarah Evans