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Recipient Registration Form - A Do-Plasma Initiative
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* Indicates required question
Name of patient
*
Your answer
Age
*
Your answer
Gender
*
Male
Female
Other:
Blood Type
*
A+
A-
B+
B-
AB+
AB-
O+
O-
Don’t know
Required
Mobile Number
Your answer
City
*
Your answer
Name of caretaker
Your answer
Mobile number of caretaker
Your answer
Relation with patient
Your answer
Name of Hospital
*
Your answer
Hospital Address
Your answer
Any other relevant information
Your answer
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