Blood Donor Form

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Full Name *

Age *

Gender *

Blood Group *

Height (in ft) *

Weight (in kg) *

Contact Number *

Email *

Present Address *

Address Line 1

City

State / Province / Region

Country

Permanent Address *

Address Line 1

City

State / Province / Region

Country

Have you donated blood before? *

If yes, how many times? *

Date of last donation *

Have you tested positive for COVID-19 in the last 6 months? *

Have you traveled abroad in the last 6 months? *

If yes, please mention the country *

Are you physically well enough to donate blood? *

If traveled (in

Declaration *

I hereby declare that the information provided above is true and accurate to the best of my knowledge. I voluntarily agree to donate blood and confirm that I am not under the influence of alcohol, drugs, or any restricted substances.

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