Request For Therapeutic Phlebotomy



Request for Therapeutic PhlebotomyFAX COMPLETED REQUEST TO (713) 790-1782 For questions, call (713) 791-6608. To download this form, visit [ABOUT DONATING]Incomplete orders are not accepted. Order expires two (2) years from date of signature. Patient’s Full Legal Name: FORMTEXT ?????Date of Birth: FORMTEXT ????? Telephone #: FORMTEXT ?????SSN: XXX–XX– FORMTEXT ???? (Last 4 digits only)To initiate this order, all patients must call (713) 791-6608 to verify order receipt and register The registration/approval process will be completed within 3 business days.Diagnosis -Reason for Phlebotomy FORMCHECKBOX Secondary Polycythemia due to D75.1Testosterone Replacement Therapy FORMCHECKBOX Secondary Polycythemia, other D75.1 FORMCHECKBOX Polycythemia Vera D45 FORMCHECKBOX Hereditary Hemochromatosis E83.110 FORMCHECKBOX Other Hemochromatosis E83.118 FORMCHECKBOX Other (Include both ICD-10 Code and Diagnosis): FORMTEXT ?????Minimum Hematocrit for PhlebotomyFOR PolycythemiaFOR Iron unloading (Hemochromatosis) FORMCHECKBOX 45% FORMCHECKBOX 33% (minimum) FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????HCT will be performed before each phlebotomy. No CBC or ferritin testing providedFrequency(Whole Blood500 +/- 50 mL)Required: FORMCHECKBOX One time ONLY Or FORMCHECKBOX Every FORMTEXT ????? week(s)Optional: FORMCHECKBOX Hold collections after FORMTEXT ????? # of collections - Request will expire once filledPatient HistoryDoes your patient have any medical contraindications or risks for phlebotomy? FORMCHECKBOX No FORMCHECKBOX Yes (If yes, explain) FORMTEXT ?????Physician Information (all fields are mandatory):Physician’s Signature: FORMTEXT ?????Date: FORMTEXT ?????Printed Name: FORMTEXT ?????Telephone #: FORMTEXT ?????Full Mailing Address: FORMTEXT ?????Fax #: FORMTEXT ?????Therapeutic patients will only be drawn on Tuesdays, Wednesdays and Thursdays between 10:00 AM and 5:00 PM unless they are approved testosterone replacement or hereditary hemochromatosis donors.Blood Center USE ONLYDeferral entry required? FORMCHECKBOX Yes FORMCHECKBOX NoReason:Deferral entry (if required), initials/date:SafeTrace ID:MD Approval/Date: ................
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