Therapeutic Phlebotomy

Request Form

HH and TRT patients being drawn ≥8 weeks apart DO NOT need a prescription if they meet allogeneic eligibility.
It is the responsibility of the patient to call (713) 791-6608 and verify their order has been processed before
scheduling an appointment or presenting at location to be drawn.
No CBC or ferritin testing provided.
Gulf Coast Blood will only draw standard whole blood units of 500 mL, +/-50mL.
Effective August 31, 2026, the Therapeutic Phlebotomy Request Form will include two minimum hemoglobin threshold options: 13 g/dL, the standard blood donor threshold, and 11 g/dL for patients requiring more frequent therapeutic phlebotomy. Please select the threshold appropriate for your patient when completing the form.
Existing orders will remain valid and do not need to be resubmitted.

Therapeutic Phlebotomy Request Form

Patient Information

Legal First Name (Required)

Middle Initial

Legal Last Name (Required)

Date of Birth (Required)

Email Address (Required)

Phone Number (Required)

Patient Mailing Address

Street Address (Required)

City (Required)

ZIP Code (Required)

Patient Diagnosis and Phlebotomy Instructions

Reason for Phlebotomy (Required)

Testosterone Replacement Therapy with Secondary Polycythemia (TRT) D75.1 Hereditary Hemochromatosis (HH) E83.110 Other

Known Communicable Disease (Required)

Yes No

ICD-10 Code (Required)

Diagnosis (Required)

Hold Collections

Minimum Hemoglobin for Phlebotomy

Ordering Provider Information and Acknowledgement

Medical Doctor Full Name (Required)

Nurse Practitioner/Physician's Assistant Full Name

Date (Required)

Order Provider Acknowledgement (Required)

Ordering Provider Signature (Required)

Provider Street Address (Required)

Provider City (Required)

Provider ZIP Code (Required)

Provider Phone Number (Required)

Provider Fax Number (Required)

Provider Email Address (Required)

Human or Robot? (Required)