Thank you for your continued interest in using LifeStream's blood services. We appreciate
our partnership with you and look forward to continuing our service to you.
To ensure that all orders for autologous and directed donations are compliant with
regulations, we have updated our forms. Separate order forms are now required for
autologous and directed blood components.
In addition, to help ensure an optimal experience for your patient, the criterion
for acceptance of an autologous donation has changed:
Effective May 2016
- Autologous donations should be completed no later than 14 days prior to surgery.
- Hematocrit must be at least 33%.
- Any exception requires LifeStream Medical Director approval.
Requests for autologous or directed blood donation service must be ordered using
the forms: "Request for Autologous Donor Blood Components" or "Request for Directed
Donor Blood Components." Multiple donations can be ordered using a single form.
Please see the below links to help you with this process:
Autologous Acceptability Criteria
Autologous Donation Protocol – a step by step guide
Request for Autologous Donor Blood Components
Directed Donation Protocol – a step by step guide
Request for Directed Donor Blood Components form
Approximate Risks per Unit of Transfused Allogeneic Blood Products
Therapeutic Phlebotomy Prescription Form
Completed forms can be mailed or faxed to:
P.O. Box 1429
San Bernardino, CA 92402-1429
*The signature of the ordering MD/DO, NP, or PA is required. Requests with the practitioner’s name signed or initialed by another individual or
“stamped” signatures will be returned for an authorized signature.
If you have questions concerning Autologous or Directed Donation Protocol, please contact a Medical Services Coordinator at 909-885-6503 (ext. 664) or 877-386-6874 or via email at MedicalServices@LStream.org.