Professional Clinical Services

Therapeutic Phlebotomy

 

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.

Patients should call the Blood Center’s 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 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

Prescription for Therapeutic Phlebotomy