Blood Donation Medication Disclosure Form
Please complete this form before donating blood so staff can review your recent and current medication use.
Donor Identification
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medication Disclosure
Current medications taken recently
*
Date of last dose
*
-
Month
-
Day
Year
Date
Are you taking any blood thinners or anticoagulants?
*
Yes
No
Not sure
Have you taken any antibiotics or other medications in the last 30 days?
*
Yes
No
Not sure
Donation Readiness and Acknowledgment
Do you understand that medication use may affect your eligibility or timing of donation?
*
Yes
No
I confirm that the information provided is complete and accurate to the best of my knowledge, and I agree to discuss any changes in my medication status with donation staff before donating.
*
I agree
Submit
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