■ 제대혈 관리 및 연구에 관한 법률 시행규칙 [별지 제21호서식]

Cord Blood Unit Supply Request Form

1. CBU Information

Cord Bank Name and CBU ID

[  ] Single Unit Transplant       [  ] Multiple Unit Transplant

2. Cord Blood Transplantation Recipient Information

Recipient Name				Sex / Age
Center Name				Physician Name
Diagnosis
Current Status
Brief History
Recipient Weight			Blood Type
HLA Type	HLA-A	HLA-B			HLA-C	DRB1			DQB1
HLA Typing Method
Proposed Transplantation Date

3. Transplant Center Information (Delivery Instructions)

Transplant Center Name
Attn./Name
Telephone		Fax
Mobile/Pager
Address Line 1
Address Line 2
City, State / Province
Zip Code, Country

Form Completed By                  Date                    Ordering Physician

Korea Cord Blood Information Center

210mm×297mm[일반용지 60g/㎡(재활용품)]