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Professional Clinical Services Therapeutic Phlebotomy
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The
acceptance of a donor for therapeutic phlebotomy is the decision of the Blood
Center’s Medical Director/Designee.
The
donor’s referring physician must complete and sign the Blood Center’s
Prescription for Therapeutic Phlebotomy.
The
prescription must document the patient’s 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.
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The
FDA and the State of New Jersey require a written request with the
Physician’s 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 physicians’ 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 |