To submit this form, complete all required fields accurately and ensure it is signed by the requesting physician or advanced practice provider. Fax the completed form to LifeSouth Community Blood Centers at 888-286-0179. Allow at least 2 business days for processing. For any further assistance, contact LifeSouth at their provided contact number. My advice is to double-check all entered information for accuracy to avoid any processing delays.

Standing orders expire one year from the request date. Ensure that orders are renewed annually if necessary.

The purpose of this Therapeutic Phlebotomy Order form is to provide a standardized way for physicians and advanced practice providers to request therapeutic phlebotomy for their patients. Therapeutic phlebotomy is a medical procedure used to remove excess iron or red blood cells from patients with specific medical conditions. This form ensures that all necessary patient information and medical indications are accurately documented for proper processing and approval by LifeSouth Community Blood Centers. By using this form, healthcare providers can facilitate timely and appropriate therapeutic phlebotomy treatments, ensuring patient safety and effective management of their medical conditions. Additionally, the form provides clear instructions and standardized fields for necessary information, helping to streamline the ordering process and reduce the likelihood of delays or errors.

• 1. Patient Information: Fields for entering the patient's last name, first name, middle name, address, city, state, zip code, email, phone number, date of birth, and sex.
• 2. Medical Condition: Checkbox to indicate if the patient has a medical condition that may increase the risk of adverse reaction and require medical supervision during phlebotomy, with space for explanation if applicable.
• 3. Indication for Phlebotomy: Checkboxes for selecting the appropriate medical condition that requires phlebotomy, such as Polycythemia Vera or Hemochromatosis.
• 4. Order Details: Fields for entering the requester's name and credentials, phone number, request date, frequency of draw, hemoglobin limits, and requester's signature.
• 5. Approval Section: Section for approval or denial by the medical director or designee, including donor ID, date, and region.

Failure to submit this form may result in delays or inability to provide necessary therapeutic phlebotomy treatments to the patient.

• Delayed Processing: Incomplete or missing forms can cause delays in processing and scheduling therapeutic phlebotomy procedures.
• Medical Risks: Patients may not receive timely treatment, potentially leading to worsening of their medical condition.
• Scheduling Issues: Inaccurate or incomplete information may result in scheduling errors and inconvenience for both patients and healthcare providers.

• 1. Polycythemia Vera: Use this form to request phlebotomy for patients diagnosed with Polycythemia Vera.
• 2. Hemochromatosis: Use this form to manage phlebotomy schedules for patients with hereditary or acquired Hemochromatosis.
• 3. Testosterone Replacement Therapy: Submit this form for patients undergoing Testosterone Replacement Therapy that necessitates therapeutic phlebotomy.
• 4. Abnormal Blood Chemistry: Use this form for patients with elevated ferritin, hemoglobin, or iron levels requiring phlebotomy.
• 5. Porphyrin Metabolism Disorders: Request phlebotomy for patients with disorders of porphyrin metabolism using this form.