Donation Request
Patient Name
Patient Age
Gender *
Male
Female
Blood Group *
A+
A-
B+
B-
AB+
AB-
O+
O-
Hospital where you are undergoing treatment *
City *
State
Mobile *
Address
Remarks
Requisition for Convalescent plasma therapy issued by treating Doctor.
I Consent to the condition.
The information provided here is complete and correct to the best of my knowledge. I authorize District Administration Kurukshetra to display my Name, Mobile/telephone Number,Email Address and/or postal address to the person who is willing to donate Plasma.
Alert Message
×
Record Updated successfully