FRM/



Hospital Name |      | |

|PULSE code |      |

|Laboratory Manager Details |

|Full Name |      |

|Telephone |      |

|Email |      |

|Laboratory IT Manager Details |

|Full Name |      |

|Telephone |      |

|Email |      |

|Laboratory Information System (LIMS ) & Version |

|LIMS:       |Version:       |

|Please confirm Electronic Despatch Note (EDN) functionality with your LIMS supplier prior to submitting this request. |

|Print Name       Dated       |

|NHSBT Use Only |

|Request Submitted to Service Desk |Submitted by:       |

| |Date:       |

| |Log Number:       |

|Account Details Received from Service Desk |Received by: |

| |Date:       |

|PULSE Enabled |Enabled by:       |

| |Date:       |

|Customer Informed |Informed by:       |

| |Date:       |

| |

|Please return completed form electronically to: NHSBT.customerservice@nhsbt.nhs.uk |

| |

|OR Post to: Customer Service, NHS Blood and Transplant, Part Academic Block - Level 2, John Radcliffe Hospital, Headley Way – Headington, |

|Oxford, OX3 9BQ |

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