DONOR REGISTRATION

Questionnaire

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

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

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

    ONLY for women: Did you have any pregnancies?
    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*