For Blood Bank use only:
ALL INDIA INSTITUTE OF MEDICAL SCIENCES, JODHPUR
Department of Transfusion Medicine & Blood Bank Request Receiving No. …………………..
Basni, Industrial Area, Phase-II, Jodhpur-342005 Received on ………………………………………..
Blood Bank: 0291-2740742 Ext#1436 Time …………………………………………………..
Crossmatch & Blood Components Release □ or Hold □ Signature ……………………………………………
Patient Name …………………………………………………..……………… Patient ID …………………………………….…………… Age/ Sex ……...………. Weight …..………
Date of Admission ………………………………………Blood Group: ………….……….…..… If child < 4 mo: Mothers Group is ……………………………......................
Father/Husband’s Name ………………………………………………….…………… Address & Phone …………….................................................................................................
Faculty In charge …………………………..….……………….. Department ………………………..…………………………. Ward ……...……… Bed/Room No ……………….
Clinical Diagnosis …………………………………….…………………………….……… Indication for Transfusion ……………..…………………………………………………….
Urgency Category: Routine □ Urgent □ Emergency Release □ Patient Category: General □ FOC □ Other specify…………………
Transfusion History ……………………………………………………………………… Pregnancy History ……………………………………………………………………………….
Hb …...….gm/dl, Hct …..….….%, PT/INR ……….…, APTT …….………, Platelet count…………/cubic mm, Fibrinogen… ...... g/dL
Units to be ordered:
BUFFY COAT/
PRBC FFP RDP SDAP CRYO SPECIAL MODIFICATION (if required)
GRANULOCYTE
Leuko Filtration Washed PRBC/Platelet Irradiation
Pediatric Unit Reconstituted WB Other
Blood Required (Date & Time: ….……………………....) Sample collected by……..……………. (Date and Time..................................... )
PLEASE PASTE PATIENT STICKER HERE Signature of Faculty / Resident
(Mandatory)
Doctor’s Name & Contact No.
INSTRUCTIONS
1. 3 ml patient’s blood in EDTA vacutainer purple top, (1ml EDTA microvacutainer is acceptable for neonates) must be sent with the Request.
2. In case of newborns upto 4 months, send another tube with mother sample also (label “Mother of ”)
3. For release, fill release request and send Insulated box to carry the Component, which will be handed over only to Hospital Staff.
.……………………………………….………….……… FOR BLOOD BANK USE …………….…………..….…………………………………
Cell Grouping Serum Grouping
Result Antibody
Auto ABO/Rh
Anti-A Anti-B Anti-D Anti-AB A cell B cell O cell Screen/ICT
control
Previous Blood Grouping Done: Yes / No ; If Yes, Previous Grouping Result: _________________Signature ______________________
CROSS - MATCH METHOD - (LISS - COOMB'S / IMMEDIATE SPIN)
Unit Unit Issue
Blood Blood Unit Unit Compatible Xm Issue Patient Component
Unit No. Date of Blood (Yes/No)
time & Recv By
Component Segment no. Vol. by by Location
Expiry Group date
✄………………………………………………………………………………………………………..……………………………………………✄...................................................................................... ✄
BLOOD REQUEST ACKNOWLEDGEMENT RECEIPT
Patient Name ____________________________________________________ Patient ID _______________________________ Ward/Bed No. _____________
Note: This is ONLY an Acknowledgement Receipt of blood request form. It does not confirm the availability of blood/blood components.
For confirmation regarding the availability of blood/blood components, kindly call ext#1436.
“This is to be retained in Patient File” For Blood Bank use only:
PLEASE PASTE PATIENT STICKER Request Receiving No. …………………..
BUFFY COAT/
HERE PRBC FFP RDP SDAP CRYO
GRANULOCYTE Received on ………………………………………..
(Mandatory) Time …………………………………………………..
Signature ……………………………………………
