Blood Donation

GET UNITED FOR BLOOD & PLASMA DONATION

Registration Form

Blood Donation

Note:- • Any person between 18-65 years of age and over 45kg weight can donate blood.

• Blood / Plasma donor related information will be kept confidential by HULAHUL FOUNDATION, Mumbai.

Please answer the following questions honestly as this may affect your health or harm the patient:

1. Do you have or have ever had any of the following?*

a. Abnormal bleeding or blood disorders
b. Heart, Kidney, Lung or Liver disorders
c. Epilepsy, Mental disorders
d. Tuberculosis or Leprosy
e. Thyroid or other endocrine disorders
f. Polycythemia Vera

g. Cancer
h. Insulin – dependent Diabetes
i. Uncontrolled High Blood Pressure
j. Allergic disorders
k. Fainting Spells

Yes No

2. Have you ever had any of the following risk factors for HIV/ AIDS, STD’s or Hepatitis?*

a. Had sex in exchange for money or drugs
b. Intravenous Drug Abuse
c. Tested positive for HIV, STD’s or Hepatitis B or C
d. Had sex with a person who has any of the above risk factors

Yes No

3. Have you had any of the following in the last 1 year?*

a. Major surgery
b. Blood Transfusion or Immunoglobulin injection
c. Dog bite or Rabies vaccination
d. Typhoid

Yes No

Declaration: I UNDERSTAND THE FOLLOWING AND GIVE MY CONSENT BY CLICKING THE SUBMIT BUTTON.

Note:

1. Blood donation/plasma is a totally voluntary act and no incumbent or remuneration has been offered.

2. Donation of blood/ components is a medical procedure with associated potential risks.

3. My blood will be tested for HIV, Hepatitis B & Hepatitis C, Syphilis and Malaria in addition to any other screening tests required to ensure blood safety.

4. My blood is separated into components- red cells, platelets, plasma and issued to patients as wells as blood banks. Excess plasma may also be sent to a fractionation center to produce albumin, globin etc. for patient use.