Lifesouth therapeutic phlebotomy form 2026

1. Click ‘Get Form’ to open the lifesouth therapeutic phlebotomy form in the editor.
2. 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.
3. 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.
4. 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.
5. 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.
6. Finally, ensure that all fields are completed accurately before signing. The requester must sign and indicate approval or denial.

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