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IRL Referral
"
*
" indicates required fields
Step
1
of
4
25%
Referral form completed by:
*
First Name
Last Name
Date
*
MM slash DD slash YYYY
Time
*
Hours
:
Minutes
AM
PM
AM/PM
Your Email
*
Patient Name
*
First
Last
Date of Birth
MM slash DD slash YYYY
Ethnicity
Select
Hispanic
White alone, non-Hispanic
Black or African American alone, non-Hispanic
American Indian and Alaska Native alone, non-Hispanic
Asian alone, non-Hispanic
Native Hawaiian and Other Pacific Islander alone, non-Hispanic
Some Other Race alone, non-Hispanic
Multiracial, non-Hispanic
Sex
Select
Male
Female
Requesting Physician
Hospital
Hospital ID
Diagnosis/Medication
Has the patient been transfused in the last 3 months?
Yes
No
Date and # of Units
Has the patient been pregnant in the last 3 months?
Yes
No
If the patient received RhoGAM, date
MM slash DD slash YYYY
Check all that apply:
Routine
STAT*
Hgb/HCT
Active Bleed?
Yes
No
Specimen Collection Date
MM slash DD slash YYYY
Do you have a request from a physician to transfuse this patient?
Yes
No
Date to Transfuse
MM slash DD slash YYYY
*Will incur additional fees
Hospital Test Results
ABO/Rh
*
Select
A+
A-
B+
B-
O+
O-
AB+
AB-
Current Antibody Screen
Select
Positive
Negative
Previously Identified Antibodies
DAT: Poly
Select
Positive
Negative
IgG
Select
Positive
Negative
C3
Select
Positive
Negative
Auto Control
Select
Positive
Negative
Describe current transfusion problem and/or Reason for Submitting:
Requested Testing to be done at CCBC
Requested Testing to be done at CCBC
Complete Antibody ID Workup (21 mL EDTA Whole Blood)
ABO Discrepancy
Level 1 Phenotype (Rh and K)
Level 2 Phenotype (extended Rh, K, Fy, Jk, Ss, MN)
*Patient RBC and HLA Genotyping Request
*Patient RBC and HLA Genotyping Request:
HLA Class I low resolution DNA Type including Antibody Report (HLA-A, B, C) (30 mL ACD-A (yellow top) & 10 mL Clot (red top) keep at room temperature)
RBC Complete Genotype (5 mL EDTA (purple top))
RBC Rh Genotype (5 mL EDTA (purple top))
RBC Weak D Genotype (5 mL EDTA (purple top))
*Will incur additional fees
*Special Product Request
Number of units requested:
Date Needed
MM slash DD slash YYYY
Time Needed
Hours
:
Minutes
AM
PM
AM/PM
HLA Matched Platelets (HLA testing already done)
Sickle Cell Testing
HCT Testing
HCT Range
Antigen Negative RBCs
Deglycerolized RBCs
Washed RBCs
Irradiated
CMV Negative
Historical or
Screened
Units negative for:
D
C
E
c
e
K
Fy
a
Fy
b
Jk
a
Jk
b
S
s
M
N
Additional
*Will incur additional fees
Blood Specimen Label Should Contain:
1. Patient Name
2. Patient identifying number (Medical Record #)
3. Date specimen drawn
4. Phlebotomist initials
Note: Incorrectly labeled specimens will not be tested
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