• Blood Donation Form

    Blood Donation Form

    Confidential - Please answer the following questions correctly. This will help to protect you and the patient who receives your blood. 
  • What is your blood type?
  • Gender
  • Format: (000) 000-0000.
  • What was the last time you donated blood?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you donated previously?
  • In the last six months have you had any of the following?
  • Do you suffer from or have suffered from any of the following diseases?
  • Are you taking or have you taken any of these in the past 72 hours?
  • Is there any history of surgery or blood transfusion in the past six months?
  • Should be Empty:
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