Blood Donor Consent Form

Gather a donor's medical history and personal details, then capture their informed consent before the blood is drawn.

Use this template

Date

Blood Unit No.

License No.

Full Name

Nombre

Apellido

Birth Date

Gender

Male Female Other Prefer not to say

Occupation

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

What is your preferred contact method?

Phone Email SMS Mail

Would you like your name included on the donor website?

Yes No

Have you donated previously?

Yes No

If yes, how many occasions?

What was the last time you donated blood?

Did you have any discomfort during or after donation?

Yes No

Do you feel well today?

Yes No

Did you sleep well last night?

Yes No

Do you have any reason to believe you may be infected with hepatitis, malaria, HIV, and/or a venereal disease?

Yes No

In the last 6 months, have you had a history of any of the following?

In the last six months, have you had any of the following?

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

Are you taking, or have you taken, any of these in the past 72 hours?

Aspirin Antibiotics Blood thinners Alcohol

Is there any history of surgery or blood transfusion in the past six months?

Surgery Blood transfusion None

For female donors only

Have you had an abortion in the last three months?

Yes No

Do you have a child less than one year old?

Yes No

Would you like to be informed of any abnormal test result at the address you provided?

Yes No

Have you read and understood all the information provided and answered every question truthfully, understanding that any false statement or omission could affect your health or harm the recipient?

Yes No

Are you pregnant?

Yes No

Weight

Pulse

Hemoglobin (Hb)

Blood Pressure (BP)

Temperature

Signature of Donor

Sign here

Signature of Medical Officer

Sign here

I confirm the information above is accurate and I consent to blood donation.

I agree

Blood Donor Consent Form

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