Self Registraion Form

  1. Donor Information:-


    6. During past 12 months have you had any of the following

    10. Have you had any of the following in the last 6 months ?

    • If you were found to be HIV positve, Hepatitis B, C or Syphilis infection
    • If you are having multiple sex partner or have engaged in male to male sexual activity
    • If you have ever worked as a sex worker or had sex with a sex worker.
    • If You have ever injected any drug (Esp. Narcotics) not prescribed
    • If you suspectthat you or your partner may have HIV or any other sexually trasmitted dieases

    15. In the last 6 month have you had :

    16 In case you are woman ?

    Consent

    I understand that:

    • Blood donation is a totally voluntary act and no inducement or remuneration has been offered.
    • Donation of blood / Components is medical procedure and that by donating voluntary. I accept the risk associated with this procedure.
    • My donated blood, blood and plasma recovered from my donated blood may be sent for _a! plasma tractionation for preparation of plasma derived medicinal products, all of which may be used for larger patient population and not just this blood bank.
    • My blood will be tested for Hepatitis B. Hepatitis C, Malaria Parasite, HIV / AIDS and diseases in addition to any other screening tests required ensuring blood safety.
    • I would like to be informed about any abnormal test result done on my donated blood