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

Thanks for submitting!

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