Plasma Donor Form

• Full Name *  

  Mr. Ms./Mrs. Master

  Gender*  

  M

  F

  Age *        

  Days

  Mnth

  Yrs

  Personal Details *            

  + 65 + 92 +974 +963 +358 +34 +355 +213 +54 +374 +61 +43 +880 +375 +32 +975 +55 +95 +237 +86 +593 +20 +33 +49 +233 +30 +592 +91 +62 +98 +39 +81 +962 +254 +371 +961 +60 +356 +52 +373 +225 +212 +258 +977 +31 +64 +234 +389 +47 +92 +970 +46 +63 +48 +351 +40 +7 +966 +381 +65 +386 +27 +82 +94 +41 +255 +66 +90 +228 +256 +380 +971 +44 +1 +58 +84 +967

  Have you tested positive for Covid-19? *    

  Y N

  Date of positive COVID-19 test? *  

  Do you have COVID-19 negative test report? *  

  Y N

  Date of negative COVID-19 test report? *  

  Address-1 *  

  Address-2 *    

  Have you donated before? *  

  Y N

  Blood Group *  

  A+ B+ O+ AB+ A- O- B- AB-

  Organisation Name  

  Organisation *  

  Alpla Cyient Biological E Limited Dr.Reddy's Dodla Dairy Elico Hyderabad Runners Infosys Quantela MYK Arment MYK Laticrete Paradigm IT Srinivasa Farms Zen Technologies Other

  Have you ever had a positive test for AIDS virus? *  

  Y N

  Do you have any chronic conditions or anything else we need to know? *  

  Have you ever been tested positive for Hepatitis B or Hepatitis C? *  

  Y N

  Did you get a tattoo in the past 12 months? *  

  Y N

  Would you be more inclined to donate if the user provides transportation? *  

  Y N

  *  

  I have read and agreed to Terms and Conditions by GiveRED

  Cancel