Jeevan Stem Cell Registry

(Unit of Jeevan Blood Bank and Research Centre)
22/11, Wheatcrofts Road, Nungambakkam, Chennai 600 034
• Phone: +91 44 4350 4246, +91 44 2826 3113
• Email:bethecure@jeevan.org
• Website:www.jeevan.org

DONOR REGISTRATION AND CONSENT FORM

(PLEASE FILL THE FORM IN CAPITAL LETTERS)

Informed Consent

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.

All above information is confidential and is for office use only.
(The Application will not be processed if the Form is not duly completed.)