Prescription forTherapeutic Phlebotomy Form

Therapeutic Phlebotomies are not available at Versiti Indiana locations. Only HH patients are accepted at Versiti Illinois.

Instructions: Complete Sections 1-3. All sections must be complete prior to submission. Contact the Special Patient Services Department at (414) 937-6188 with questions or to change the therapeutic phlebotomy order.

Please Note:

Any value entered on the form must be a whole number; no decimals are allowed.

* Please indicate State where phlebotomy will occur

Illinois Michigan Ohio Wisconsin

* Diagnosis (HH only in IL)

Erythrocytosis Hereditary Hemochromatosis Hemochromatosis Polycythemia Vera Porphyria Secondary Polycythemia Testosterone Replacement Therapy Other

Section 1:

Ordering App/Physician Information

* APP/Physician First Name

* APP/Physician Last Name

* Email

* Office Contact

* Phone

Fax

Section 2:

Patient Information

Please note the Date of Birth field defaults to today’s date. Please be sure to change this to the patient’s Date of Birth.

* Patient Legal First Name

Preferred Name

* Patient Last Name

* Date of Birth

* Gender

Male Female Other

* Patient Contact Phone

Non-HH patients must meet allogeneic Hgb criteria: > 13g/dl for males and 12.5g/dl for females.
If Ferritin is less than 50ng/mL, the patient may not be phlebotomized more than once every two months.
Versiti does not perform Ferritin testing.
Current Ferritin is for HH or iron overload patients only

* Current Hemoglobin (Whole numbers only, no decimals.)

Current Ferritin (Whole numbers only, no decimals.)

Section 3

Phlebotomy Order

Please note that new prescriptions are required after 1 year.

HH and TRT patients being drawn > 8 weeks apart do NOT need a prescription if they meet allogeneic eligibility.

Only HH and TRT patients are eligible to potentially donate Dual Red. This option should not be checked for first-time donors.

HH and TRT patients prescribed Dual Red must meet all allogeneic eligibility or a whole blood will be drawn instead.

* Frequency of Phlebotomy

Once a Week Every 2 Weeks Monthly Every 2 Months Every 3 Months PRN (no more than 1 phlebotomy per week) Other

* Phlebotomy Volume to Withdraw

One unit of whole blood (max is 500mL) Dual Red (Not Available in OH) Specific Amount

HH Patients Only:

Only hemoglobin levels are available at drawing sites.
Hemoglobin level is generally equivalent to Hematrocrit 3. Please specify hemoblobin level.
Per Versiti policy, patients will not be drawn if hemoblobin is lower than 11g/dL.

Hemoglobin level must be over 11 g/dL to be eligible.

* Do not draw if hemoglobin is below

* Physician Signature Consent

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Prescription forTherapeutic Phlebotomy Form