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HEREDITARY HEMOCHROMATOSIS AND TESTOSTERONE THERAPY PHLEBOTOMY ORDER

All information MUST be filled out in its entirety to be considered valid.

Please fax completed form to (405) 297-5598 ATTENTION: Donor Special Coordinator For Questions please call (405) 297-5597

PATIENT INFORMATION

Patient Name:

D.O.B.(mm.dd.yyyy)

Mailing Address:

Gender

   Male   Female

City:

State: (xx)

Zip Code:

Phone Number:
(xxx)xxx-xxxx

Alternate Number:
(xxx)xxx-xxxx

All orders are for whole blood collection procedures; approximately 500 mL of blood will be removed from the patient with each collection.

  1. Reason for draw:

    Hereditary Hemochromatosis         Testosterone Therapy needing phlebotomy

  2. Frequency (mark ONE of the following DO NOT write in additional frequencies .):

      Weekly      Every 2 weeks      Every 4 Weeks      Every 8 Weeks  

  3. Hematocrit/Hemoglobin:

    Patients WILL be drawn to a minimum Hematocrit (HCT) level of 39%.

    The blood institute does NOT perform ferritin levels and cannot perform phlebotomy for ferritin levels.

ERROR MESSAGE: ALL REQUIRED FIELDS ARE NOT COMPLETE!!

Please complete the areas highlighted red before attempting to print. Incomplete forms will not be accepted.

****For Hereditary Hemochromatosis patients ONLY****

If phlebotomy is needed to lower HCT below 39% document below.

Phlebotomy should NOT be performed if HCT % is less than:

Some draw locations perform Hgb testing. At these locations minimum Hgb will be calculated as HCT ÷ 3.

Ordering Medical Care Provider Signature:


Date: (mm.dd.yyyy)

Printed Ordering Medical Care Provider Name:

Office Phone:
(xxx)xxx-xxxx

Fax:
(xxx)xxx-xxxx

ABI/OBI/TBI/CMBC Personnel Only

BECS Patient ID:


Date order receiveded:


Tech ID:


Date deferrral entered:


Tech ID:


Date order expires:


Date order entered into BECS:


Tech ID:



Comment Section:


Reviewed by:


Date Reviewed:


Facility Name: Sylvan N. Goldman Oklahoma Blood Institute 1001 N. Lincoln, Oklahoma City, Oklahoma 73104. The official copy of blood bank documentation is the electronic copy on file with the local area network. The official copy of records created from forms is paper unless designated otherwise.


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