Jeevan Stem Cell Registry
(Unit of Jeevan Blood Bank and Research Centre)
22/11, Wheatcrofts Road, Nungambakkam, Chennai 600 034
Mobile: 8939999216 • Email:email@example.com • Website:www.jeevan.org
DONOR REGISTRATION AND CONSENT FORM
(PLEASE FILL THE FORM IN CAPITAL LETTERS)
I hereby consent to the taking of a blood sample / buccal swabs in order to carry out HLA typing. I transfer ownership of the
blood sample / buccal swabs to JSCR. I have been informed by JSCR that the typing of my blood sample and the admission
into the database serve the purpose of finding a matching donor for patients.
1) I have given consent to be a voluntary peripheral blood stem cell / bone marrow donor.
2) I confirm the correctness of my personal data above and I agree that it is stored
at JSCR in order to search for donors.
3) I will make myself available for confirmatory tests when required.
4) I will keep JSCR updated about any change in my contact details.
5) I agree to being contacted by JSCR through the mobile and / or email.
6) I have the option to change my mind about being a voluntary donor at any time.