Online Response Slip for Platelet Donation
Yes, I would like to be a platelet donor:
My Particulars are:-
(
All Fields
in this section are required)
Name:
NRIC/Passport No.:
Address:
Date of Birth:
(DD/MM/YYYY)
Gender:
Male
Female
Race:
Blood Group:
(ie. A+ or A-)
Regular Blood Donor:
Yes
No
Contact Information:
(Please enter at least one contact infomation)
Tel No: (Home)
Tel No: (Office)
Mobile:
Pager:
Email Address:
Fax:
I would prefer to come for screening
on
(DD/MM/YYYY)
at
AM
PM
The patient I wish to donate platelets to is :-
Patient's Name:
NRIC No.:
Gender:
Male
Female
Ward/Bed No.:
Blood Group:
(ie. A+ or A-)