Doctor’s Office:
Forward this completed and signed form and a
signed
Informed Consent for
Transfusion
form to the Medical/Ambulatory Daycare Unit where the transfusion
will take place.
Medical/Ambulatory Daycare Unit:
Forward a copy of this form to the
Laboratory.
(click field)
(click field)
choose product
Red blood cells
Platelets
Other
Other:
Ordering Physician Name
"Electronically Signed"
Signature
Date
Physician with hospital privileges (if necessary)
"Electronically Signed"
Signature
Date
(Please choose one option)
YES
NO
(Please choose site)
Royal Columbian
Eagle Ridge
Burnaby Hospital
Surrey Memorial
Delta Hospital
Peace Arch
Ridge Meadows
Mission Memorial
Langley Memorial
Abbotsford
Chilliwack General
Fraser Canyon
Subject: