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Blood Beneficiary Form
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Blood Beneficiary Form
Blood Beneficiary Form
Inquiry ID
Date
Time
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00
30
Donor ID 1
*
Donor ID 2
Donor ID 3
Applicant Name
*
Applicant Phone Number 1
*
Applicant Phone No. 2
Applicant Email ID
Patient Gender
*
Male
Female
Other
Patient Gender
Patient Age
*
Patient Name
*
Hospital Name
*
Are Applicant/Beneficiary/Other Family Member/Friends Willing to Donate Blood ?
*
No
Yes
You Have to Fill Form as Donor, Before Availing Donation
UID
Regn. Date
*
Regn. Time
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
00
30
Donor Full Name
*
First & Last Letter of Your Name Will Be Displayed Publically on Our WhatsApp
Gender
*
Male
Female
Transgender
Other
Gender
Suburb / Area
*
Suburb/Area Name Will Be Displayed Publically on Our WhatsApp
City
*
City Name Will Be Displayed Publically on Our WhatsApp
State
*
State Name Will Be Displayed Publically on Our WhatsApp
Country
*
Country Name Will Be Displayed Publically on Our WhatsApp
Birth Year
*
Birth Year of Donor Will Be Displayed Publically on Our WhatsApp
Mobile Number
*
First & Last Digit of Phone Number Will Be Displayed Publically on Our WhatsApp
Alternate Mobile No.
Alternate Number Will Not Be Displayed Publically on Our WhatsApp
Email
Email ID Will NOT Be Displayed Publically on Our WhatsApp
Last Date Of Blood Donated
*
Last Date of Blood Donation Will Be Displayed Publically on Our WhatsApp
Blood Type Combination
*
A+
A-
B+
B-
AB+
AB-
O+
O-
Blood Group Will Be Displayed Publically on Our WhatsApp
Do you suffer from any Disease ?
*
No
Yes
Disease Will Be Displayed Publically on Our WhatsApp
Name of The Disease, Describe Your History in Remarks Field.
*
Disease Name Will Be Displayed Publically on Our WhatsApp
Directly Who Can Contact You ?
*
JainHelpLine Volunteer
Beneficiary
Hospital Authority
Other
Other
Source of Contact Will Be Displayed Publically on Our WhatsApp
Remarks
Visual
Text
Remarks Will Not Be Displayed Publically on WhatsApp
Disclaimer
*
We are just Facilitate Donor's Data. We are not responsible for any direct/indirect losses/damages occurs out of using this data. You are using this information at your sole discretion for which none of our volunteer to be held responsible.
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