+91 44 28263113 / +91 44 43504246
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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)

1. Personal details

MaleFemale

 
 

2. Contact details

 

Address of Close Relative / Friend:(*)

 
 

3. Medical Information

(Please Answer the following Questions Correctly)

YesNo
YesNo

Have you had any of the following illnesses in the past?

YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo


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.)