Children's Medical Center
One Children's Plaza
Dayton, OH 45404
Emergency Release of Red Blood Cells
| || |
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: ________________________________________________
|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:________
Online referral form
Did you know you can make a referral to any of our specialty clinics online? Use the form below to submit directly to central scheduling.
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