Hospital Forms
 
Obtaining Forms

BloodCenter of Wisconsin provides a variety of order forms for its hospital and physician customers. These forms are related to services provided by our Hospital Services, Transportation, Special Patient Services and Diagnostic Laboratories divisions. You may view and print the forms by using the links below, order a pack of forms for delivery, or call us at 414-937-6312 for more information.

Hospital Services Forms

Customer Feedback Form
Use this form to report an event that exceeded or did not meet your expectations for customer service.

Hospital Blood Product Order Form
Use this form to order a blood product.
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Transfer Form
Use this form to transfer a blood product from one hospital to another.
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Returned Products Pick-Up Form
Use this form to Fax information to BCW to pick up returned products.
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Return Form
Use this form to return a blood product.
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Packing Guidelines for BCW Hospital Customers
Use this job aid to properly pack appropriate blood products to be returned to BCW. If you have questions, please call Hospital Services at 1-866-682-5663.
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Pharmaceutical Product Order Form
Use this form to order a derivative product.
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Pharmaceutical Product Order Form - 340B Products
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Circular of Information for the Use of Blood and Blood Components

 Circular of Information Memo              

   Addendums 

   Babesis

   Zika


Transfusion-Related Acute Lung Injury (TRALI) Mitigation Strategy
This policy outlines BloodCenter of Wisconsin strategy to reduct the risk of TRALI, comply with AABB standards and improve the safety of the blood supply. 
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Donor Management/Testing/Transportation Forms

Donor Management: Recipient Transfusion/Infusion Event Report Form
Use this form to report an adverse transfusion or infusion event to BloodCenter of Wisconsin.
Donor Management: Suspected Transfusion Related Acute Lung Injury (TRALI) Report Form
Use this form to report a suspected transfusion related acute lung injury to BloodCenter of Wisconsin.   
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Positive Bacteria Point of Care Reporting Form
Use this form upon a reactive point of care bacteria test result for a platelet product.

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Test Request Requisition
Use this form to request infectious disease testing, ABO/Rh typing, red cell antibody screening, or other testing required.
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Transportation: Sample Pick-Up Form
Use this form to request a sample pick-up.
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Transportation: Sample Pick-Up Label
Use this label on the container used to transport samples.
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Therapeutic Services Forms

Autologous Donation Prescription Form
Physicians must use this form to order an autologous donation.
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Directed Donation Order Form
Physicians must use this form to order a directed blood donation.
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Special Product Request Form
For hospitals or blood centers requesting matched platelets or granulocytes.
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Blood Transfusion Information
This is a brochure providing general information on blood transfusion.
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Cellular Therapy Product Collection Request
Use this form for cellular therapy product collection.
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Cellular Therapy Product Collection Information Form
Use this form to provide information for cellular therapy product collection.
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Prescription for Therapeutic Phlebotomy
Physicians must use this form to order therapeutic phlebotomies.
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Therapeutic Phlebotomy Patient Registration Form
Physicians must use this form to provide new patient information for registration.
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