ae ggenetiay prior teocnalenens Pie narra SWASTHYA KALYAN BLOOD BANK |i iscscsicitecs etcrinvaen, | (Regional Blood Transfusion Centre) hence 125, Milap Nagar, Tonk Road, Jaipur-302018 (Raj) [Senos ave erat om Pg Na Ph: 0141-2721771, 2545203 [Efrat opus sae Patents Name ar (Block Letter) x ee Wars Dae | Sex ane ote Hosa Teepe No. Bed wane 1 Toprone No. Dagnasis Paced RBS [une TW WW _| Ciicat note & reasons fr tention Iu on ate oof ia] B58 patna seal sr No.of Ut] Bad wo oto pal oe neve Ransom bone To. of Une] Feo of proves Fansalon A Unis | 1 oom ow Fran Fron 1. of Unie} Boat bag no Pana PoWEISOPROPFFPI = Bood Group 5 wn ot unis] Boos Bank Ne. of Uns) Dat of anstusion [Een Tata] Pascon any ‘BTUT wars HET EDTA @ Plain Screw Capp Gam StH More arzeen& aoe ae eats eT Be ee HH ‘ange oer ae tht RR ae are 1 es a Ges A ea ae sea "MtbePatentis Woman; 1, (A) Has she ever been Pregnant YesNo (2) Any Sw-inhs or miscariags YesNo 2. Her Caer (it any) loca with Heemalye ease fnew tor, YesINe Name of Blood Donors (1) 2 ®. DECLARATION FROM ATTENDING DOCTOR | sll personaly supervise the transfusion and shall check the blood taa for hasmavss. denticaion othe patient ste. before starting transtusion. {have taken informed censent from PatlenUPatenteattendent SloodSenkshll obo response for any untoward tansusion reaction, management o ranfusion and tansfuscn reactions shall be the responsibty ofthe undesied | have examined the Blood Donor, and they arent protessionalPais Biz Donor & ft er blood donation, on preminay screening. INSTRUCTIONS ON THE REVERSE HAVE BEEN NOTED BYME In‘ormed Consent From Patient's Attendent . Has BeonTaken & kept in the record. (For use by the Blood Bank only) Doctor's Signature witha seal Semple Received at ofthe Hosplal ne ae Signature of Person receiving the sample atthe 8.8, PRTENTE CELL PATIENTS SERUM aA TAanvas | ae [anal [ arb | Bod Gram — |Get [Bote [Oot recat] Bos Grup Oa a SS comes] 800 | cee | cep et] foe ES ‘od Bag Tube No ‘Match tponent | a fh Type | Saline |[Savear | sunenr | “Sila 108 No. oie ee Signature of THI En : Receipt No. ISSUING OFFICER,USE BLOOD COMPONENTS FOR COMPLETE & PROPER USE OF WHOLE BLOOD sexes nfo / 1047 pot oe: afte, eer eer es sah: ste aratrr, 2546288 fri 17, vers boverdt: 2724008 Ba ewastyapt egmatcom Wr Fare Sea sas Fas (torre ars ier B=) were 126, Pram ame, cle ts, TIGR-302018 (Ta) Request for Issue/Cross Match of Blood/Blood Components It is eamestly requested that a special effort be made tc recruit non remunerated voluntary replacement blood donors from amongst relations of the recipient. Professional or paid replacement donors will not only be rejected but they are banned by the Supreme Court of India. INSTRUCTIONS 4. Replacement Donorsivolurtary donor card must accompany request form, service charge shall have tobe paid by each one. Pleasetake full medical history of Blood Donor. Send 3ml, blood in a plain, dry, sterile test tube and 2m blood in EDTA tube with proper identity of the patient, specially the Patients name & Registration number and keep 2 C.C. with you for checking at your end. Please checkidentity ofthe patient & label ofthe blood sample before sending, Pleasealso send mother's blood sample for infants upio 3 month of age. Brief clinical notes mustbe given, emphasising the importance urgency, clearly. Supply of blood for transfusion is subject to the availaoity & prioity of the recipients, decided by he offcers-in-charge, blood bank. en Noose Dr. S.S. Agarwal (Hon. Secretary) Note : Delay in meeting the request is likely to occur unless all the queries in this form are satisfactorily answered. When transfusion is planned, Blood may be got cross matched in advance upto 72 hrs. witha & aftr tq aT: arty eet Re RTF GT PRT Hee awa a EH AT TT WH A HAART HT gee fore ren 8 fore weg wis dey A rae al eas ew ARR aT ears es & aR / STC aT GT ‘Beare oe Roa ot a en & PBA aaa em aT tea a aa argh gee Pare feed argh aor aT wae! aor as ts HeRraT sons atfeea, aye FTA, Baer 7, ReMER AR, EGE GH: 0141-2335569 eae Rares Bear ars ae tas eiRea my, ft-139/e, fetta ae, rod wort er, sree FE, TE ‘gir : 0141-2761870 Sar eared wear ars tas daar etic, arate ee, stsre, Taye Fit: 0141-2220290 (Upcated on 1.08.17) ‘SKBBIREGIOY