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Lifesouth therapeutic phlebotomy form 2026

The document outlines the Therapeutic Phlebotomy Order process for LifeSouth Community Blood Centers, detailing physician instructions, patient eligibility criteria, and necessary acknowledgments for patients with specific medical conditions. It includes sections for patient information, indications for phlebotomy, order details, and a required acknowledgment form for patients diagnosed with Hereditary Hemochromatosis or Secondary Polycythemia due to Testosterone Replacement Therapy.

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Click ‘Get Form’ to open the lifesouth therapeutic phlebotomy form in the editor.
Begin by filling out the 'Patient Information' section. Enter the patient's last name, first name, middle name, street address, last four digits of SSN, city, state, zip code, phone number, date of birth (DOB), and sex.
Indicate if the patient has a medical condition that may increase the risk of adverse reactions during phlebotomy. Select 'Yes' or 'No' and provide an explanation if applicable.
In the 'Indication for phlebotomy' section, check all relevant diagnoses that apply to the patient. Ensure you understand any additional acknowledgments required for specific conditions.
Complete the 'Order Details' section by entering who requested the procedure (MD or RN), their phone number, and request date. Specify hemoglobin levels and frequency of draw as needed.
Finally, ensure that all fields are completed accurately before signing. The requester must sign and indicate approval or denial.

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Do I need a prescription for therapeutic phlebotomy?

Therapeutic Phlebotomy and Therapeutic Apheresis Therapeutic Phlebotomy clients must make an appointment by calling their local donor center and must have a prescription from their doctor.

What is the protocol for therapeutic phlebotomy?

The FDA stated that therapeutic phlebotomy for patients must be done free of charge only if the units are to be entered into the allogeneic blood supply, while it is still acceptable to charge for phlebotomy if the units drawn from a haemochromatosis patient at the facility are discarded.

How to get a therapeutic blood draw?

To begin, a Enrollment/Prescription for Phlebotomy Form must be submitted by your physician. The physician must disclose the diagnosis requiring phlebotomy and any other health concerns (infectious disease or heart/lung issues).