Karaiskakio Foundation

Karaiskakio Foundation

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Donor registration

Questionnaire

    Are you 18-45 years old?

    Are you in good health?

    Do you have any medical condition we should know of?
    If YES, please describe:

    Are you taking any medication?
    If YES, please describe:

    Please complete:
    Weight    Height

    ONLY for women: Did you have any pregnancies?
    If YES, how many:

    Information

    Name*

    Last Name*

    ID number*

    Date of Birth*

    Gender* MaleFemaleOther

    Address*

    City*

    Mobile Number*

    Email*

    Name of a close fiend or relative*

    Telephone number of this person*

    Delivery of the saliva sample collection envelope

    Consent