Emergency Release of Red Blood Cells

Print this page Bookmark and Share

Children's Medical Center
One Children's Plaza
Dayton, OH 45404

Emergency Release of Red Blood Cells

Patient Name:__________________________________________________

 


Medical Record Number:_________________________
                                                     --or--
Account Number:_______________________________


Date:______________

Time:______________

I request immediate release of blood for emergency transfusion. I understand that compatibility testing has not been completed at the time of release. The above patient's clinical condition is sufficiently urgent to necessitate transfusion of uncrossmatched blood.

Signature of ordering Physician:___________________________________________, MD


If the ordering Physician is not immediately available to sign the order, I assume full responsibility for obtaining the Physician's signature and returning this form to the blood bank as soon as possible:

Signature of responsible person:________________________________________________

Printed name:                            ________________________________________________


Patient ABO/Rh:___________

Unit Number Unit ABO/Rh

Compatibility result at time of release

Not Done           Incomplete

Release by Release time Final compatibility result
             
             
             
             
             
             
             
             

Received by:__________________________              Tech:________             Time picked up:________

 

Sign up for Pediatric Link

Finding the latest trusted child health and safety information doesn't have to be hard. Pediatric Link, Dayton Children's e-newsletter offers timely and up-to-date information for health care professionals from the experts you trust at Dayton Children's.  Sign up

Upcoming Events

The 29th Ghost N' Goblins 5k Run and Walk registration. The 5k Run/Walk benefits Dayton Children's Hospital.

Voyage on the Parkway: a fun event for families with preschool aged children.

Child car seat safety check by certified technicians

View full event calendarView full event calendar

The Right Experts

Just right for all kids

Accreditations

The Children's Medical Center of Dayton Dayton Children's
The Right Care for the Right Reasons

One Children's Plaza - Dayton, Ohio - 45404-1815
937-641-3000
www.childrensdayton.org