FOR HOSPITALS HOSPITAL FORMS

MEDICALLY PRESCRIBED PHLEBOTOMY FORM

THE BLOOD CONNECTION

F.D.S 1636A

SELECT A CENTER*

Date Prescription Written*

Patient Gender*

Patient Race*

Patient First Name*

Patient Last Name*

Patient D.O.B*

Patient Address*

Patient City*

State*

Zip Code*

Patient Phone Number*

Format Requested: 555-555-5555

Patient Email

NOTE: If polycythemia or hemochromatosis is a result of Testosterone Replacement Therapy, please select Testosterone Replacement Therapy.

Primary Diagnosis*

Hemochromatosis/Excessive Iron

Testosterone Replacement Therapy

Polycythemia/Excessive RBC

List Any Major Illness Within the Past Year*

if none type N/A

List Current Medications*

if none type N/A

Phlebotomy Frequency*

Prescribed Hgb Level*

Select Prescription Expiration*

Pick Short Term Date*

The expiration date will be auto-calculated by our system.

Physician Printed Name*

*I understand the physician printed name will be used as my e-signature

Physician License*

Physician Office Name*

Provider NPI*

Physician Office Telephone*

Format Requested: 555-555-5555

Physician Office Fax (Optional)

Format Requested: 555-555-5555

Physician Office Email*

Physician Office Address I*

Physician Office City*

Select a State*

Zip Code*

Contact Nurse Name*

Contact Nurse Phone*

Format Requested: 555-555-5555

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