Professional Clinical Services

Therapeutic Phlebotomy

The acceptance of a donor for therapeutic phlebotomy is the decision of the Blood Centerís Medical Director/Designee.

The donorís referring physician must complete and sign the Blood Centerís Prescription for Therapeutic Phlebotomy.

The prescription must document the patientís diagnosis and address any significant medial history.

The prescription must be renewed every 12 months.

A therapeutic unit may not be used for transfusion purposes.

Patients should call the Blood Centerís Special Donor Services Department at (201) 444-3900 to schedule an appointment.

The FDA and the State of New Jersey require a written request with the Physicianís signature for a Therapeutic Phlebotomy

Instructions:† To get a copy of the form click on the link below. The form is not valid unless there is a physiciansí signature on it.Please print the form, complete all information and†sign it.

Fax it to:(201) 444-1885.

The original must be mailed within 7 (seven) days to the address below:†

Community Blood Services††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Bergen Community Regional Blood Center†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† P.O. Box 39†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Paramus, NJ† 07653-0039

Attention: SDS Therapeutic Phlebotomy

Prescription for Therapeutic Phlebotomy