I Want to Be a Donor Full Name: This field is required. Email: This field is required. Phone Number: This field is required. Date of Birth: This field is required. Address: This field is required. Are you feeling healthy and well today? Yes No Have you donated blood before? Yes, regularly No, this will be my first time Are you at least 18 years old and weigh over 110 lbs (50 kg)? Yes No In the last 6 months, have you: Had a tattoo or piercing? Yes No In the last 6 months, have you: Traveled outside the country? Yes No In the last 6 months, have you: Been diagnosed with an infectious disease? Yes No How soon would you like to donate? I’d like to schedule later Within the next month This week Preferred contact method: Phone Call ⬜ Email WhatsApp/Text Message Submit There was an error trying to submit your form. Please try again.
