JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Saamarthya - COVID Patient Form
Hey,
We know these are trying times & will try our best to support you every step of the way in taking care of you and/or loved one.
We will try our level best to connect you with a donor that is located in your vicinity to ensure the donation is as convenient as possible for you, at the earliest opportunity.
Hope you and/or your loved one gets well really soon. You are a true warrior 🔥! Please take care of yourself as well, don't tire yourself out & stay safe!
Inserting a few links here in case you want to reach out to us!
Email Address-
saamarthyavolunteers@gmail.com
Instagram- @_saamarthya_
https://instagram.com/_saamarthya_?igshid=10747er3dz6uo
Twitter- @_saamarthya_
https://twitter.com/_Saamarthya_
Facebook-
https://www.facebook.com/Saamarthya-104818407939403/
You may also visit our website and check out our work under Project Vinita further:
https://saamarthya.wixsite.com/saamarthyavolunteers
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name
*
Your answer
Type of Requirement (Oxygen, Injection, Plasma, etc)
*
Your answer
Date of Infection
MM
/
DD
/
YYYY
Plasma Requirement, if any
A+
A-
B+
B-
O+
O-
AB+
AB-
Any
Blood Group
A+
A-
B+
B-
O+
O-
AB+
AB-
Any
Blood Group
Other Requirement, if any
Your answer
Locality
*
Your answer
City
*
Your answer
State
*
Your answer
Contact Person
*
Your answer
Contact Number
*
Your answer
Additional Comments, if any
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms