Blood Donor Information:
First name
Last name
Date Of Birth
Your email
Your Mobile No.
Your Address:
Blood Type: -O+O-A+A-B+B-AB+AB-
Did you Donate Blood Before?: YesNo
When Was the Last Time you Donated Blood Before?:
Health Security Check
Do you Suffer from any Diseases?: YesNo
Diseases: —Please choose an option—HepatitisAgranulocytosisAsthmaCholesterolDiabetesOsteoporosisThyroid DisordersKidney DiseaseFluAnxiety DisordersTendonitisBursitisDepressionOther
Other Diseases?:
Do you Suffer from any Allergies?: YesNo
Allergies: —Please choose an option—AspirinAmoxicillinPenicillinIbuprofenSulfaCetuximabLamotrigineDilantinPollenMoldLatexNickelChromiumFungicideHouse dustFormaldehydeCosmeticsOther
Any Other Allergies?:
Have you ever had Positive Blood test for HbsAg, HCV, HIV?: YesNo
Do you have any Cardiac Problems?: YesNo
Do you suffer any Bleeding Disorders?: YesNo
Do you take any Medication?: YesNo
Please describe the Medication you take::