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:_________________________
Account Number:_______________________________



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:________


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

We are driven by our values of safety, compassion, ownership, collaboration, innovation and value creation. We are looking for individuals to join our team who embody these values and support our mission of improving the health status of all kids in our region. We hope that might be you! Come to our job fair to learn more about our open opportunities.

View full event calendarView more events...

The Right Experts

Just right for all kids


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