Lifesouth wp-contentuploadsTherapeutic Phlebotomy Order - Lifesouth Community Blood Centers 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Patient Information section. Enter the patient's last name, first name, middle name, address, city, state, zip code, date of birth (DOB), sex, email, and phone number.
3. Indicate if the patient has a medical condition that may increase the risk of adverse reactions during phlebotomy. If yes, provide an explanation.
4. Select the appropriate indication for phlebotomy from the provided options. Ensure you check only one box that applies to the patient's condition.
5. In the Order Details section, print and include your credentials as the requester. Fill in your phone number and request date.
6. Choose the frequency of draw by selecting one option and specify any hemoglobin level requirements if applicable.
7. Sign as the requester and indicate whether the order is approved or denied. Ensure all fields are completed before submission.
8. Fax the completed form to 888-286-0179 and allow at least 2 business days for processing.

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