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*1PO×PRINT AMBULATORY BLOOD COMPONENT ORDER FORM Page 1 of 1Doc. #3312 Rev. 04/09/2013LOCATION DATE OF SERVICE TRANSFUSE IF IRRADIATEDPATIENT IS NAME PHONE #DATE OF BIRTHDAY OVER UNITS OF CMV NEGATIVE
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Provide your personal information, including name, contact details, and identification number.
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Specify the date and time of the ambulatory blood component.
05
Fill in the required medical information, such as the reason for the blood component, any related medical conditions, and pertinent medical history.
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Provide details about the healthcare provider who will be responsible for the administration of the blood component.
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3312 ambulatory blood component is required by individuals who:
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- Need to undergo certain medical procedures or surgeries where the provision of blood components may be necessary.
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- Have a medical condition that requires regular or periodic blood component administration for treatment or maintenance.
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- Have experienced excessive blood loss or anemia and need blood components as part of their recovery or treatment plan.
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- Are participating in medical research or clinical trials involving the use of ambulatory blood components.
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3312 ambulatory blood component is a form used to report information related to blood components collected and transfused in an outpatient setting.
Healthcare facilities and providers that collect and transfuse blood components in an outpatient setting are required to file 3312 ambulatory blood component.
The form should be filled out with detailed information about the blood components collected and transfused, including donor information, type of component, quantity, and recipient information.
The purpose of 3312 ambulatory blood component is to ensure proper documentation and tracking of blood components collected and transfused in outpatient settings for patient safety and regulatory purposes.
Information such as donor details, component type, quantity collected and transfused, recipient details, date of collection and transfusion, and any adverse reactions must be reported on 3312 ambulatory blood component.
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