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Sharing scheme registration form
Please complete the form below to join our blood sharing scheme.
Practice details
Practice name
*
Staff contact name
*
Practice address line 1
*
Practice address line 2
Postcode
*
Town/city
*
Name of corporate group (if applicable)
Contact number day
*
Contact number night
*
Email address
*
Email address for invoices and statements
*
Canine blood products stocked (please tick and note corresponding number of units if applicable)
Packed Red Blood Cells - Positive
Yes
No
Number of units stocked
Packed Red Blood Cells - Negative
Yes
No
Number of units stocked
Fresh Frozen Plasma
Yes
No
Number of units stocked
Frozen Plasma
Yes
No
Number of units stocked
Cryo-precipitate
Yes
No
Number of units stocked
Cryo-supernatant
Yes
No
Number of units stocked
Temperature monitoring
What temperature monitoring do you have in place for your blood products?
Continuous
Max/Min Thermometer
Other
None
How frequently are temperatures checked and recorded?
Twice Daily
Daily
Weekly
Never
Blood sharing availability
When is sharing available at your practice?
Day sharing (9am - 5pm)
Night/ weekend sharing (after 5pm)
Transfusion referrals
Are you happy to be recommended for transfusion referrals?
Yes
No
Comments
Please note any comments/ special instructions
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