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Prescription for Therapeutic Phlebotomy Form

Prescription for Therapeutic Phlebotomy

Therapeutic Phlebotomies are not available at Versiti Indiana/Ohio locations. Only HH patients are accepted at Versiti Illinois.

Instructions: Complete Sections 1-3. All sections must be complete prior to submission. Contact the Special Patient Services Department at (414) 937-6188 with questions or to change the therapeutic phlebotomy order.

Please Note:

  • Any value entered on the form must be a whole number; no decimals are allowed.
Section 1:

Ordering App/Physician Information

Section 2:

Patient Information

  • Please note the Date of Birth field defaults to today’s date. Please be sure to change this to the patient’s Date of Birth.
  • Non-HH patients must meet allogeneic Hgb criteria: > 13g/dl for males and 12.5g/dl for females.
  • If Ferritin is less than 50ng/mL, the patient may not be phlebotomized more than once every two months.
  • Versiti does not perform Ferritin testing.
  • Current Ferritin is for HH or iron overload patients only
Section 3

Phlebotomy Order

Please note that new prescriptions are required after 1 year.

HH and TRT patients being drawn > 8 weeks apart do NOT need a prescription if they meet allogeneic eligibility.

HH and TRT patients prescribed Dual Red must meet all allogeneic eligibility or a whole blood will be drawn instead.

HH Patients Only:

  • Only hemoglobin levels are available at drawing sites.
  • Hemoglobin level is generally equivalent to Hematrocrit 3. Please specify hemoblobin level.
  • Per Versiti policy, patients will not be drawn if hemoblobin is lower than 11g/dL.

Hemoglobin level must be over 11 g/dL to be eligible.

I affirm that by checking this box I am the patient’s treating provider and I confirm all information to be correct and accurate and acknowledge this acts as my digital signature.

* Fields are required.

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