Pleare *end labeltsd 3 cs clotl*d and *ce f;0TA hl**d s*rnptes in capped

${ sq. ts
&SVEfrHI*EHT SF I]YE$T EfrHfrAL
Form Na" ?4
HEAt_Tr{ & TAMILy WtLfAfiE f}EpeftT[jtEf{T
STETE HLOS D THANSFUSION SEfiV*CS
st&+D i fi*&pfitrE$tT REQUI$tTtOfi FSRiJl SF 6SW" BLSSS S*llr{

!'larne of Plrysiciff* I Surgeon

I Saie $t .eqrJrsiticn

Addres of tIls Fs,*icfit {Fer treelrlent at h*rfle}

4. How thq Slsed sheutdbs i$su*d :
ie^n
Jir B! FAn
L'Leve
a illl/
s.l'.ir
lcF
!r+b r "_ v
nll,

{i} lnd,gdnr t6ttach Govt. erploy*e csrlil}q*tg / xerar copy *f lfidisi*fii sertitisale
l* cas* sf Gor.l. HsEFilall
{ri} Fay}nelrt

{iiii Sts{{t dqn*ti*n ;iredit &s{d.

5. Har*e *{ Fatie}* ."".._. tcaprtal t*etterri
6. r\ge Sex -. ..

Fatient's fieg. lta

7 \,i,';iicl lic. .. .. ..- .ilc.j lj* .. , .. .....p1,s nan Ns

B. Daie of admirli+n . .

3 DiaEnosis
Sample teceited. Date,...-. ..... . Ime.. ......

10. lndioaliofi ror {ra*$fusron : {*ck which is apptieable}

ff *cute Hasrrlorrhag€ S Roufi*e furg€ry [! f*e*oaa*i,la C fr{fi*enital **ae*ria

[ *cute Li{e savi*g s,;rgen; fi nrt
frhrorrh A*aemla
respondi*g to lrcElm€.1ls
fl Cere*r ar$ I ar C}xnr$he*epy

f! r.iverdissrs* $ ffisaaguhriontlisorder frorn*{pmwepacig}

14, Any transrilsisn *t Blood i Compo*enl ift ths Ba$t sr rerefilly {Bag Flo.}

1S. Whal is required ? ffo*c H&C I Whste blood I Plasma / C4o precipitate / F.F.P l ldrash*d R.8.0. / plat*iets I &l$re
Ig. Suantity .............. Unite.

, tsrrup and Hh Faetar m*st bs meiltion*d if pruviou"*tyet*d!

22. Wherr r,vani*d i-l ' "2 ir*r-rre [] I hor:rs cr niore ...Whsther to he kept in res*rve ? yes I No

F*ciaratian : t dsciara th+t i have prr$f,nally draran and tabe*ed this sampte afid I ds luetily tk* need lsr
transfusien i* thie p*tlur:

0uu;ll*rsi5n*d by Heqilisitiane<r by
il*;rg:tilii*n ,, iieg. Fia. pf pf ;r.i;:1;.1 ,; Tinne & Date Designation 1 Reg. No, of Fhysician
r'..r:j: f-,'f Ni:fpT fiF "FRE$H SLgOe" $AES r{OT EXIST
Si;";iit-r Ullit: Y*A;$$F[JSISN HAS Vgpy L*TLE UTILITY
 rliurslog Hsrtt: or by an o{l**r autharts€d bv
A,il rr:iiuu,t;rnl niusi trn fjrlti i.rr.,ft1c,slqJled.,lf.t11 ,Sun'.' 1lr^nn:l-:' I-,fYl
ii;ile sGic o;;ice fu3i liE i'lleriiiQllt}tj *n tf* requlsllion
'l11i-'s(!pcl-!{rl,*nd*ni iri! hl5 c1'\1fl lLsf^'i's'".1j.,,""'ln,, deb'*Ildii'}il
will nol be served'
&equililiorr not FroprilY countetsigned'
sampios 2.5 ini. ciol|q6 94rnpl,3e 1?l a scres$dfi iiisi iube ano anolnDf screwca0 Iest lube 1., fiii
lrrstruclrbn rcqrrrdrng,,:n.Jrfl!
',r B,ioclr ,fl nnc rngln irl CDTA
spectal Eare r-nlri,t be takofi lhal lhey are proper{y labellqtj in Das(at Letters,,!itf:
llillle st:rrrjrne o*1 ramplgs ior cross.malttrtng,
* hfspila} aflrj ihs daie on the sample lr'rlres Tc auttd rnt:lakes
i.jili,iro *i th{r puiJfiflt. ti:ri t:r:ti.:*erd*n0""?'i]:t1I..-, "T-*.oi
pt*;tsc iJrlvu attrl hl.rr:i ';lrrtpiu>;iJ;ij;r';i -iiJ Pot'cir! al a ilili6'

3
lne;esriiijai bi':ric in lh* packel and iniorrrt iiru Eintri Suni(
o{ ,t}aclrons, 1-rlea;r pres*;r'''e
requigliio* belliJeerr 10 trr 14 00 nours ofl lv*ek days & beuveen J* r0 1?'3& hours
:irr:L;irl sen# lh*fr
or-t
F$vatrr Nr.riitiri! l"lornCS
S*rlrrlaY flr SundaY
ilnil$ ar€ stlppit*d alter qc,esning tor rnfeuironsrrrarker$ lt:r r]Oil-i*Atliv;ty
VS*L' liiv-l & 2,
"qii i:l***: / hi*.d fc,ftfcflettt perlotm€d accordrng lo it't qurdelrne ol Drreclorai* General oi Heaith $ervrce & I'Jational
lest *re
tlCV, HssAg an, MP sc''*e.;ng
Bio$u F*lri:y

rSfl USE IN BLOOil SAf'IK ONLY

D-^ il^ fiasfi$ Patch No.

l rE.a4. lYv. ......".
Lot No

licc.J!",*d el fiag Nn

Pl 5 Lir0trp ..

Slored Blcod
.jtolP,..,. Palment

EiliNa.
Quantily ,

blc*{ .....,,...... Numbei ol txehanss Doilors

Na. *i Stared

issued iry Tir*e

Comp*tibility Test idlaic>r Mirrsr &a^oir,ari h,,

Saline 'lime

Coomh r;

i}pr, lljbi

{Please if cantPatible}

"rlJE CSNfrEpT QF'.rRE*H

B'*ofin" noES NOT SXIST
$lNGi-E UNi-i,1-ll4qgtuStOr.; HAS V€fiY t"lTTLE UTil-lTY