Received on……… At…………….. Signature…...………

                                                 REGIONAL BLOOD TRANSFUSION CENTRE
                                                                                         (WEST-ZONE)
                                                                DEEN DAYAL UPADHYAY HOSPITAL
                                                   Harinagar, New Delhi – 110 064 Phone : 25494402-08 Extn. 393
                                                                                                                                                         Issue No.:……...…………
                                                                       BLOOD REQUISITION FORM

Nursing Home/
Hospitals Name :……………………………………....
…………………………………………………………
Patient’s Name:………………………………………..
(in capital letters)
Father's/Husband's Name................................................

FOR THE USE OF BLOOD BANK
Blood Group & Rho:..........................................
Tested by:.........................................................
X-Matched bag No/s:...........................................
Tested by:.........................................................
X-Matched by:...................................................

Whole Blood/Packed Cells/Plasma/Platelet conc.
Patients Regd./Admn. No.:……………………………………………..….. Age :………….………. Sex:…….…….....…....
Doctor Incharge………………………………..…….. Ward ………………..…………. Bed/Room No …………...............
Clinical diagnosis with short history: …………………………………………………….………………………...…..……..
……………………………………………………………………………………………………………………...…….……
Routine or Emergency (with justification)………………………………………………………………………...…………..
History of Previous Transfusion………….n………………Yes/No if yes. ABO group………….….. Rh……...…………..
Reaction if any…………………………………………………………………………….……………………...…………...
If Patient is Woman : Has she ever been pregnant……………………………. Yes/no Para…………………...………….....
                                   History of HD NB/Still birth/miscarriage.
No. of units Reqd …………………………….……… on ……………….………………… at ………..…....……………...
Dated : ……………………….. Time : …………….………  

                                                                                                 Signature of the Medical Officer
                                                                 With Designation & Stamp of Nursing Home/Hospital

                                      INSTRUCTIONS
.
1 5 ml patients blood in plain steril labeled test tube (12 x 100 mm) with topper must be sent with the requisition from in a 
new born baby upto 4 month old, send the mothers blood sample also. The label should have patient’s  name,
 Adm./Reg.No., hospital/nursing home name and date.
2. All requests must accompany replacement donors.
3. The requisition must be filled complete in all respects. Patients name, Regd./Adm. No., Ward, Bed/Room No. and Nursing
Home/hospitals name should be the same both on the form and blood sample label. It should be legible otherwise
requisition will not be accepted.
4 Blood and its products must be taken when required for definite use, normally once issued it will not be taken back
5 Relatives must be told to bring a thermocole container to carry the blood/its products, otherwise it will not be taken back.
6  Requisition forms for routine demands are accepted between 9.30 a.m. to 3.00 p.m. on working days. Lunch break
between 1.30 p.m. to 2.00 p.m.
7 Requisitions for emergency requirements are accepted round the clock.
8 Blood will be issued after about 3 hours of receiving the requisition and blood sample.
9 Incomplete form will not be accepted.
10 Blood group must be specified.
11 Stamp of Nursing Home/Hospital is must.