Nama : ........................................................................................................
Alamat : ........................................................................................................
No.Register : ........................................................................................................
Jenis Komponen Darah : ........................................................................................................
Jenis Reaksi : ........................................................................................................
Kronologis Kejadian : ........................................................................................................
Tindak Lanjut
Tangerang,...........20....
Yang membuat laporan
Catatan : Mohon labu yang menimbulkan reaksi transfusi dikembalikan ke Bank Darah FORM-LAB-14-00