Blood / Blood‑Component Request

Patient Name *

Patient name is required.

Age (years) *

Valid age is required.

Gender *

Male

Female

Please select gender.

IP Number *

IP number is required.

Room Number *

Room number is required.

Blood Group & Rh *

Blood group is required.

Referring Doctor *

Referring doctor name is required.

Hospital Name *

Hospital name is required.

Diagnosis / Remarks

Previous Blood Transfusion *

Yes

No

Please select an option.

Any Transfusion Reaction? *

Yes

No

Please select an option.

Required Date *

Please select required date.

Required Time *

Please select required time.

Units Needed *

Please enter number of units needed.

Whole Blood

Red Cell Concentrates

Platelet Concentrate

Fresh Frozen Plasma

REQUEST FOR BLOOD & BLOOD COMPONENTS