"Healthical.in - Your Health Our Priority "

Full Name *

Date of Birth *

Mobile Number *

Email *

Select Blood Group *

Weight *

Last time donated blood date *

Have you ever been deferred or rejected as a donor *

Current Living City *

Address *

Any medical conditions or allergies *

Please specify:

Any medication that you are currently taking *

Please specify:

How did you hear about Healthical's blood donation drive *

By submitting this form, I declare that I am in good health and am willing to donate blood voluntarily in case of a medical emergency or as required by Healthical. I understand that Healthical will use my personal information only for the purpose of blood donation and will keep my information confidential.

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