TN Logo Plasma Donor Registration, Government of Tamil Nadu
தன்னார்வ பதிவு, தமிழ் நாடு அரசு
Covid 19
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Plasma Donor Self Registration
District Name*
Taluk Name
Village Name
Plasma Donor Name (50 Chars)*
Gender*
Age*
Address*
Mobile No. (+91)*
Re-Type Mobile No. (+91)*
Date of Diagnosis *
Positive Confirmation Report Date *
Hospital Treated with Reg No.
Date of Discharge
Negative Confirmation Report Date/Date of Complete Recovery
Brief Clinical History
Consent : I understand that, 1. Plasma donation is a voluntary act & no inducement or remuneration will be offered
2. My blood will undergo various screening tests required to ensure safety of the unit collected.
3.My donated plasma may be given to patients (currently infected with COVID-19), who are likely to benefit from it. I am eligible & give my consent on the above understanding for donating plasma.
*
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* represents mandatory field(s).
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