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VOLUNTARY PLASMA DONOR REGISTRATION FORM
Plasma Donor Data Base, IMA Charitable Blood Bank, Kanpur
Phone-0512-2983830, Mobile-8887633960
* Indicates required question
Email
*
Your email
NAME
*
Your answer
FATHER' S NAME
*
Your answer
GENDER
*
MALE
FEMALE
TRANSGENDER
AGE
*
18 yrs. to 60 yrs.
Your answer
BLOOD GROUP
*
O+Ve
O-Ve
A+Ve
A-Ve
B+Ve
B-Ve
AB+Ve
AB-Ve
OTHER
I Don't Know My Blood Group
WEIGHT
*
in Kilograms
Your answer
Hemoglobin Level
*
Remark - Persons having haemoglobin level 12.5 g/dl are not eligible for plasma donation
Less than 12.5 gm
Greater than 12.5 gm
I don't Know my Hemoglobin Level
In case of female
Not Pregnant
Pregnant
Clear selection
Mobile Number
*
Enter 10 digit valid mobile number
Your answer
ADDRESS
*
Your answer
NEAREST LAND MARK
*
Your answer
PIN CODE
*
Your answer
HAVE YOU BEEN DIAGNOSED WITH COVID POSITIVE EARLIER
*
YES
NO
DATE WHEN YOU WERE DIAGNOSED WITH COVID POSITIVE
*
Date
MM
/
DD
/
YYYY
HAVE YOU BEEN VACCINAED WITH ANY COVID VACCINE
*
YES
NO
DATE OF 1ST DOSE OF VACCINATION IF YES
Date
MM
/
DD
/
YYYY
DATE OF 2ND DOSE OF VACCINATION
Date
MM
/
DD
/
YYYY
ANY ILLNESS
*
Your answer
DECLARATION
*
I would like to donate my plasma voluntarily.
I hereby declare that all the information furnished above is true and correct to the best of my knowledge and belief.
Required
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