Recipient request

Hospital blood request

No account required. Complete these steps to submit your official request form.

Requester Information

Step 1 of 3

Full name

Full name is required.

Age

Age is required.

Phone number

Phone number is required.

Email address

A valid email address is required.

Address*

Enter address manually

House / street / landmark

Region

Province

City / municipality

Barangay

Complete address

Delivery

Red Cross staff will coordinate the delivery with you or the receiving hospital.

Delivery date

The date you need the blood delivered by. Red Cross staff will confirm the schedule with you.

Select the delivery date.

Patient & Blood Details

Step 2 of 3

Patient full name

Patient full name is required.

Age

Patient age is required.

Sex

Select sex.

Status

Select status.

Blood type

Select blood type.

Components

Select component.

Units needed

Enter 1 to 20 units.

Diagnosis / transfusion indication

Diagnosis or indication is required.

Attending physician (printed name & signature)

Attending physician is required.

Official hospital form

Step 3 of 3

Please upload the official hospital blood request form containing the attending physician's signature.

Upload hospital request form

PDF, JPG, or PNG up to 10MB

Choose file

Review request details

REQUESTER -

PATIENT -

BLOOD DETAILS -

PATIENT STATUS -

DELIVERY DATE Not set

RELEASE METHOD For delivery