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Registration Form For Plasma Donation
Ahmedabad Chapter of WIRC of ICSI organises Plasma Donation Drive with Support of Indian Red Cross Society
* Indicates required question
Name of Member/Student
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Your answer
Membership Number/Registration Number
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Your answer
Name of Plasma Donor
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Your answer
Mobile Number
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Your answer
E mail id
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Your answer
Age of Plasma Donor (18 to 60 Years)
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Your answer
Full Address
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Your answer
Pin Code Number
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Your answer
Gender
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Male
Female
Blood Group
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A+ (A Positive)
A- (A Negative)
B+ (B Positive)
B- (B Negative)
AB+ (AB Positive)
AB- (AB Negative)
O+ (O Positive)
O- (O Negative)
Date on which you were Recovered From Covid-19
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MM
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DD
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YYYY
Have you taken Vaccine?
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Yes
No
Date of 1st Dose of Vaccine
MM
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DD
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YYYY
Date of 2nd Dose of Vaccine.
MM
/
DD
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YYYY
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