Blood Request Form

Please send 3ml of clotted blood and 2ml of EDTA blood labelled with the Patient's Name, Age & Admission / IP No. For Neonates (< 1 month old baby), kindly send 2ml EDTA sample of mother also.

Patient Details

Indication for Transfusion

Pre-Transfusion Values

g/dl
x 103/ul
sec
sec
%
mg/dL

Components

Tree Id Product UOM No.Of Units Reserved Required Date & Time Diagnosis
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