FRM/ - Microsoft



Please enter appropriate RCI department details in box below and FAX completed form to the relevant RCI department.

|RCI: |

Do not fax this form until the sample package has left your department

****ALL URGENT REFERRALS MUST BE TELEPHONED****

|Referring |Hematos |

|Hospital:       |Code:       |

|Sent by |

|(Print and sign name):       |

|Date and time package dispatched:       |

|Method of transport NHSBT Transport Hospital Transport Courier/Taxi |

|(tick one): Post Other |

|Signature (if appropriate): |

|Contact telephone number: |Hospital Transfusion Laboratory Fax number: |

|      |      |

Details of samples sent:

|TO BE COMPLETED BY REFERRING HOSPITAL |TO BE COMPLETED BY NHSBT |

|Patient identifier (patient name if possible) |No. of samples from |Date and time sample(s) received in RCI (sign |

| |this patient |for receipt) |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

|Sample package unique ID (if using):       | | |

NHSBT use only – tracking discrepancies found (select one)? YES / NO

|Details of any tracking discrepancies found and action taken (sign and record date and time): |

|      |

| |

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