Con
Cell Corp PAT & PRP Services Group
1283 Route 311
Patterson, NY 12563
Phone: 845-878-7711
/ Fax # 845-878-7733
Facsimile Request for Autotransfusion
Services: Date:
Name of Caller/Person Completing Form:
Hospital:
(phone#)
Patient:
Surgeon:
Procedure:
Procedure Date:
Procedure Time:
Comments (PAT/PRP):
Reason for Fax:
Booking:
Change:
Cancellation:
NOTE:
A TELEPHONE
CALL MUST BE PLACED TO THIS OFFICE FOR ALL EMERGENCY REQUESTS OR PROCEDURES
REQUIRING SERVICES THAT ARE
SCHEDULED WITHIN THREE BUSINESS DAYS.
IF
YOU ARE RESERVING OR SCHEDULING REQUESTS ONE WEEK IN ADVANCE, PLEASE
FAX THE INFORMATION TO THE CARMEL OFFICE,
845-878-7733.
*** The
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entity named above. If the reader of this message is not the intended recipient, or the employer or agent
responsible to deliver it to the intended recipient, you are hereby notified that any distribution or copying of this communication
is strictly prohibited. If you have received this communication in error, please notify us immediately
by phone and return the original message to the above address by mail.***