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BLOOD DONATION DRIVE
First Name
Email Address
Last Name
Date of Birth
Are you willing to be conatcted when we conduct our Blood Donation Drive?
No
Yes
Have you donated blood in the last 6 months?
No
Yes
Do you have any kind of ailments?
No
Yes
Do you have any of the following?
Sugar
Hypertension
I have been operated on
I am allergic
I had a tatoos / piercings done in last 6 months
I have engaged in "at risk" sexual activity
Fit as a Fiddle
I declare that the info I’ve provided is accurate & complete
SUBMIT
Thanks for submitting!
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