J.J. MEMORIAL DIAGNOSTICS & HOSPITALS (P) LTD.

LOKOPRIYA GOPINATH BORDOLOI AVENUE , DIBRUGARH – 786001

Phone no – (0373) 2300147, 2302470 EXT.NO. 23 Fax no : (0373) 2302761

E-mail : jjmemorial.hospitals@rediff.com

To ,

THE MEDICAL OFFICER BLOOD BANK

DR. DAMANIS NURSING HOME / ADITIYA HOSPITAL /ASSAM MEDICAL COLLEGE/ AROGYA BHAWAN

DIBRUGARH ASSAM.

SUBJECT – Requisition of whole human blood / Packed cell/ function.

Dear Sir,

I am sending the husband /wife / guardian / relative of the patient whose name is

1)

2)

3)

4)

The collection of …………………………….unit of blood for my / our patient whose particulars are given
below.

Name of patient ………………………………………………………… Age…………………… Sex………………………………………

Chinical Diagnosis………………………………………………………………………………………………………………………………….

Blood groups & Ruhr of patient…………………………………………………………………….Hb%................................

Nature of treatment :- Conservative/ operative.

N.B . under the above particulars, I would like to request you to kindly issue me the ………………………units

Of blood along with the full serology and Hb% test reporting and Hb% of the Blood donner.

Thanking You. Yours Faithfully

Date : ……………………………… (For J.J.Memorial Hospital)