Blood Donation Deferral Form
Please complete this form for individuals who are temporarily or permanently deferred from donating blood.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Deferral
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Deferral
*
Temporary
Permanent
Reason for Deferral
*
Please Select
Recent illness or infection
Recent travel to restricted areas
Medication use
Low hemoglobin/iron
High-risk behavior
Other
If 'Other', please specify the reason
Deferral Duration (if temporary)
Please Select
1 month
3 months
6 months
12 months
Other
Additional Comments or Notes
Staff Member Completing Deferral
*
Donor Signature
*
Submit Deferral
Submit Deferral
Should be Empty: