|
Sex
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Address
|
|
Primary Phone
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Cell Phone
|
|
Email Address
|
List any medical conditions that could impact safety such as cardiac, vascular, pulmonary disease, or positive infectious diseases.
|
|
Diagnosis, Hgb Threshold, Draw Volume and Frequency
|
|
|
Polycythemia
• • •
|
If Other, Specify
|
|
Polycythemia
• • •
|
If Other, Specify
|
|
Draw if Hgb is at least ___g/dl
|
|
|
Hemochromatosis
• • •
|
If Other, Specify
|
|
Draw if Hgb is at least ___g/dl
|
|
|
Porphyria Cutanea Tarda
• • •
|
If Other, Specify
|
|
Draw if Hgb is at least ___g/dl
|
|
|
Other
• • •
|
If Other, Specify
|
|
Diagnosis: (Vitalant FMD approval required)
|
Draw if Hgb is at least ___g/dl
|
|
Ordering Healthcare Provider Information
|
|
|
NOTE: The ordering healthcare provider must have privileges in the state where the phlebotomy will be performed.
|
|
|
Name
|
Provider State
|
|
License#
|
Address
|
|
Phone Number
|
Fax Number
|
|
Person Completing form
|
Date
|
|
Vitalant Use Only
|
|
|
Date Order Received
|
Valid through Date
|
|
FMD Name (if approval is needed)
|
|
|
Protocol Information
|
|
|
Donor ID
|
Therapeutic Fee
|
|
Protocol #
|
Therapeutic Deferral added
|
|
Patient#
|
NA-HHITT Donor
|
|
EC/Date
|
|
|
Subsequent Protocol #
|
EC/Date
|
|
Subsequent Protocol #
|
EC/Date
|
|
Comments
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