Rashtrotthana Blood Centre

Principal Sponsor: Smt. Subhadraben Jayantilal Nagardas Shah (Jain)

Blood Donation form

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Your ID number will help us to track your donation

Blood Group will be verified after donation

If you provide the contact details, it help us to contact you for if any adjective result of the blood

(To be filled during the donation process.)
(To be filled during the donation process.)
(To be filled during the donation process.)

(Note: Before blood donation, one should have adequate food, a minimum six hours of sleep is a must, if not one may have to face into word reaction)

Eligiblity Criteria

● Unexplained weight loss
● Continious Low-grade fever
● Repeated Diarrhoea
● Swollen Glands
● Tattooing Ear Piercing
● Blood Transfusion
● Dental Extraction
● Minor Surgery

● Steroids
● Aspirin

● Cancer/Malignant Disease
● Heart Disease
● Abnormal bleeding tendency
● Unexplained weight loss
● Diabetes controlled on insulin
● Hepatities B/C
● Chronic Nepehrities
● Sexually trans diesease
● Liver Disease
● Tuberculosis
● Polycythemia vera
● Asthama
● Epilepsy
● Leprosy
● Schizophrenia
● Endocrine disorders
● Allergic disease
● Hypo/Hyper tension

● Hepatities in family or close contact
● Typhoid
● Dog bite/Rabies vaccine
● Blood Transfusion (Individual/Spouse)
● Major surgery
● Immunoglobulin
● Jaundice
● Tattooing/Body Piercing/Acupuncture (Individual/Spouse)

● Cholera
● Typhoid
● Diphtheria
● Tetanus
● Plague
● Gammagloulin

Eligiblity Criteria

Eligiblity Criteria

● Are you pregnant
● Are you having your periods today?
● Have you had an abortion in the last 6 months
● Do you have a child less than one year old

I understand that
a) Blood donation is totally voluntary act and no inducement or remuneration has been offered.
b) Donation of blood/components is a medical procedure and that by donating voluntarily, I accept the risk associated with this procedure.
c) The surplus plasma component will be utilised for fractionation and derivation of essential plasma derived medicines.
d) My blood will be tested for Hepatitis B, Hepatities C, Malaria Parasite, HIV/AIDS and venereal diseases in addition to any other screening tests required to ensure blood saftey.
e) Any abnormal tests results will be informed at the address furnished.
I prohibit any information provided by me or about my donation to be disclosed to any individual or government agency without my prior permission.

I have read and understood all the information presented and answered all the questions truthfully. I have acknowledged that any incorrect statement or concealment may affect my health or may harm the recipient.