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Community Blood Bank 2646 Peach St. Erie, PA 16508 REQUEST FOR ISSUE OF BLOOD AND/OR BLOOD COMPONENTS PRIOR TO THE COMPLETION OF PROCESSING The following is/are required for: Patient: ________________________________________________________ Hospital ID #: ___________________________________________________ Hospital: _______________________________________________________ Date: ___________________________ Time: _________________________ on an emergency basis prior to the completion of processing (blood typing, antibody screening, and/or infectious disease testing) and/or compatibility tests: DONOR UNIT # COMPONENT PRODUCT CODE I believe this patient’s life will be in jeopardy without the above emergency transfusion. Therefore, I accept the responsibility for and release the Community Blood Bank of Erie County personnel of the responsibility for any adverse patient reaction resulting from this transfusion which may have been prevented by pre-transfusion blood processing. Physician Name (Please Print)_____________________________________________________ Physician Signature*_______________________________ Date: ________________________ * Federal regulations require the attending physician’s signature be obtained for all issue of blood or blood components prior to the completion of processing. This form must be completed and signed by the attending physician for all emergency issue of blood or blood components. Please return the signed copy to the Community Blood Bank, 2646 Peach St. Erie, PA 16508 REV. 10.12 (RELEASE OF BLOOD/BLOOD COMPONENTS PRIOR TO COMPLETION OF PROCESSING)