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Blood Donors Registration Form

Home / Donar Registration

Blood Donors Registration Form

Please provide the requires Details as all fields are Mandatory.

Personal Details

Donor's Name*

Date of Birth*

Age*

Gender*

Email*

Mobile No.*

Phone No.

Id Proof

Contact Details

Address Line 1*

Address Line 2

Address Line 3

District*

Pin Code

Preferred Means of Contact

Special Instruction

I don't want to disturbed between (DND)

At Night
During Official Hours
Mannual Timings
Other Instruction If Any

Other Information

Have You Donated Previously

Yes No

Your Blood Group*

Do You know your Weight?*

Do You know your Haemoglobin Count?*

Name of the Blood Center you want to be associated with*

Select all that Apply

I am in Good Health

Have You any reason to believe that you may be infected by either Hepatitis, Malaria, HIV/AIDS, and/or Venereal Disease?

Yes No

In the last 6 Months have you had any history of the following:

Unexplained Weight Loss
Repeared Diarrhoea
Swollen Glands
Continuous Low-Grade Fever

In the last 6 Months have you had any:-

Tattooing
Ear Piercing
Dental Extraction

Do you suffer from or have suffered from any of the following Diseases?

Heart Diseas
Lung Disease
Kidney Disease
Cancer/ Malignant Disease
Epilepsy
Diabetes
Tuberculosis
Abnormal bleeding tendency
Hepatitis B/C
Allergic Disease
Jaundice
Saxually Trans. Disease
Malaria
Typhoid (Last 1 yr.)
Fainting Spells

Is There any history of surgery or Blood Transfusion in the past 6 Months?

Major Surgery
Blood Transfusion
Minor Surgery

I have read and understood all the information presented above and answered all the questions to the best of my knowledge, and hereby declare that

I agree to display my name and mobile on SBTCUP website with my consent.
I am ready to donate blood if requested by Blood Center/ patients/ patients relatives voluntarily on my own free will, without any expectation of replacement of blood, or any favour in form of cash or kind.
Donation of Blood/ Components is a Medical Procedure and I accept the risk Associated with Blood Donation Procedure.
My Blood or Blood products may be utilized by the Blood Center for unknown recipient requiring blood/blood products or may be disposed off as per Blood Center norms or Government policy.
I fully understand that voluntary blood donation is a humanitarian service and the persons demanding my blood may be in the state of stress. I hereby declare that under such circumstances I shall patiently handle the situation and keep my cool while contacting me even if during Odd hours/time. In case of unavoidable circumstances I shall write to SBTC, UP to withdraw my offer as voluntary blood donor and to remove my name from voluntary blood donor list on the website without any conflict.
My Blood will be Tested for Hepatitis B, Hepatitis C, Malaria Parasite, HIV and Venereal Diseases in addition to any other screening tests required for ensuring Blood Safety.
All disputes are subject to Lucknow Jurisdiction only.

Your Personal Information is Never Sold nor will We Share with Any of There Company or Organization without Prior Consent.

Contact Us

bsupsacs@gmail.com

State Blood Transfusion Council Uttar Pradesh
7th Floor, Mandi Parishad Bhawan,
16, A.P. Sen Road, Charbagh,
Lucknow, Uttar Pradesh- 226001

Phone: 0522-2638898
Fax: