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Referral Form: (Blood Assurance Program)

The document is a referral form from the Philippine Red Cross Western Visayas Regional Blood Center for a patient to receive a blood transfusion. It includes the patient's name and hospital, the number of units and blood type needed, and spaces for signatures approving the request. It also has return slips to document the services provided, including the patient's information, units served, and signature of the staff member.

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Stephen Ortencio
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583 views1 page

Referral Form: (Blood Assurance Program)

The document is a referral form from the Philippine Red Cross Western Visayas Regional Blood Center for a patient to receive a blood transfusion. It includes the patient's name and hospital, the number of units and blood type needed, and spaces for signatures approving the request. It also has return slips to document the services provided, including the patient's information, units served, and signature of the staff member.

Uploaded by

Stephen Ortencio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PHILIPPINE RED CROSS

Western Visayas Regional Blood Center


Iloilo City

DATE: ______________________

REFERRAL FORM
(Blood Assurance Program)

To Philippine Red Cross- WVRBC Staff-on-Duty:

Please accommodate patient _____________________________________________________

confined at ___________________________________ Hospital to avail of _________ unit of type

___________ of _______________________ component. Processing fees will be charged to the patient.

Coordinating Group:______________________________________________
Date of MBD: ___________________
End of Referral Date: _________________

___________________________________
Signature over Printer Name of Coordinator

APPROVED BY:

DENNISE ROY M. PASADILLA, MD


Blood Center Manager

RETURN SLIP: Donor Recruitment Officer’s Copy

Name of Patient: ________________________________________________________


Address: ______________________________________________________________
Blood Type: _____________ Component: __________________________________
# of Units Served:______ Date Request is Served: ________________________
Signature of Staff-on-Duty: _______________________________________________

RETURN SLIP: Referring Group/ Organization’s Copy

Name of Patient: ________________________________________________________


Address: ______________________________________________________________
Blood Type: _____________ Component: __________________________________
# of Units Served: ________ Date Request is Served: ________________________
Signature of Staff-on-Duty: ________________________________________________

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