Form: CA_Blood_Bank_Order_Form_Initial.html,CA_Blood_Bank_Order_Form_Viewer.html
To:
Subject: CA Blood Bank Order/Inventory-
SeqInc:
Msg:
REQUESTING HOSPITAL:
Hospital Tech Name:
Date/Time:
Leuko-Reduced Red Blood Cells (RBCL)
O Positive> SL: ACTUAL: ORDER:
O Negative> SL: ACTUAL: ORDER:
A Positive> SL: ACTUAL: ORDER:
A Negative> SL: ACTUAL: ORDER:
B Positive> SL: ACTUAL: ORDER:
B Negative> SL: ACTUAL: ORDER:
AB Positive> SL: ACTUAL: ORDER:
AB Negative> SL: ACTUAL: ORDER:
TOTALS> SL: Actual: Order:
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Leuko-Reduced Irradiated Red Blood Cells (RBCLI)
O+, cmv-> SL: ACTUAL: ORDER:
O-, cmv-> SL: ACTUAL: ORDER:
A+, cmv-> SL: ACTUAL: ORDER:
A-, cmv-> SL: ACTUAL: ORDER:
TOTALS> SL: Actual: Order:
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Leuko-Reduced Platelets (APLT)
PLATELETS A/T> SL: ACTUAL: ORDER:
PLATELETS Irr> SL: ACTUAL: ORDER:
TOTALS> SL: Actual: Order:
Special Instructions:
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Frozen Plasma (200-399ml)
O> SL: ACTUAL: ORDER:
A> SL: ACTUAL: ORDER:
B> SL: ACTUAL: ORDER:
AB> SL: ACTUAL: ORDER:
TOTALS> SL: Actual: Order:
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Single Cryo (CAF) Pooled Cryo (CAF PL)
CAF A> SL: ACTUAL: ORDER:
CAF AB> SL: ACTUAL: ORDER:
CAF PLA> SL: ACTUAL: ORDER:
TOTALS> SL: Actual: Order:
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Additional Comments from Requesting Hospital:
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Below This Line for SDBB Staff Use
NOTEPAD AREA:
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SDBB HSR Filling Order:
Date:
Time: