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

Did you have any surgery in the last 5 years? YESNO
If YES, please describe:

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

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

Now please complete the electronic form below:

Name*

Last Name*

ID number*

Date of Birth*

Gender* MaleFemale

Address*

City*

Mobile Number*

Email:

Name of a close fiend or relative*

Telephone number of this person*

I have read the donor information leaflet and I wish to register as a volunteer bone marrow donor. With my registration I am willing to provide a graft to any patient in the world in need. *
I know that I stay in the registry until I turn 60 years old unless I request that I am removed from the registry earlier. *
I consent that my saliva sample is used for tissue typing and or infectious disease markers. *
I confirm that the information I have provided is correct. I agree that they may be stored, analyzed and used for registry purposes. *