Emergency Release of Red Blood Cells

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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:________


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One Children's Plaza - Dayton, Ohio - 45404-1815