Welcome to Bloodsavers - Service Reqest Form

Service Request Form

	Name & Title:
	Customer Reference:
	Telephone:
	Address:
	Purchase Order No:
	Invoice To:
	Location for Procedure:
	Bleep/Extension:

	Cell Salvage
	Date:
	Time	(Please state am/pm)
	Type:	Intra-Op Post-Op
	Patient Information:	(Please include hospital no., patient D.O.B and gender)
	Ward:
	Clinical Indication	(Operation to be performed and medical info)
	Other Relevant Information	(eg Jehovah's Witness)

Blood Savers will contact you within 24 hours of receipt of this form. If the procedure is planned within 7 days, please contact John Pooley on 07860 957471.

Blood Savers representative/technician will contact the Customer on the day/evening prior to the planned procedure to confirm the above arrangements. In order to do this it is vital that the following information is given: (If the information is the same as above, please indicate by writing “as above”)

	Contact Name:		Telephone Number:
	Title		Extension/Bleep Number:
	Ward		Tel/Ext Number: