Donor Recruitment Form

Pre-Qualifying Questions

Yes
No

*If yes – the cannot register and the following message should be reflected

Yes
No

*If yes – the cannot register and the following message should be reflected

Yes
No

*If yes – the cannot register and the following message should be reflected

PERSONAL INFORMATION

SXXXX
Male Female
Singapore Citizen Permanent Resident Others
Chinese Indian Malay Others

OTHER CONTACT DETAILS

DONOR MEDICAL EVALUATION

Yes No
Yes No
1) Anaemia (more than one occurrence) 7) Eczema and/or Hives 13) Hypertension

























Your Consent


A DONOR FOR EVERY PATIENT