Your name Your email Date of Birth Phone Number Location

Eligibility & Health Screening (Pre‑Assessment)

Have you donated blood before? YesNo If yes, when was your last donation?

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Are you currently on any medication? YesNo If yes, please specify:

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Do you have any known medical conditions? YesNo If yes, please specify:

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Have you experienced any of these in the past 14 days? FeverInfectionRecent surgeryNone of the above

Additional Information

Emergency Contact Name Emergency Contact Phone Do you have any questions or special needs?

Consent

Consent By submitting this form, I confirm that the information provided is accurate and that I am willing to participate in the blood donation drive, subject to final medical screening.