Hero Blood Donor Form

Name as on Cedula or passport

Blood Type A+ Pos
A- Neg
AB+ Pos
AB- Neg
B+ Pos
B- Neg
O+ Pos
O- Neg

Cedula or Passport

Place of Work or (retired)

Civil Status Married
Single

Email

Phone

Other Phone

Town You Live in :

Sex Male
Female

Birth Date

Age

Have you traveled outside panama in last 3 months Yes
No

Have you had Covid-19 in last 3 months Yes
No

Date of Last Blood Donation

Health Status Normal
In Treatment

0%

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*er:

You Qualify If:

You are Between 18 and 65 years old

Minimum weight (110 lbs)

In good health

No Covid since Sept 21, 2023

Not traveled out of Panama since Sept 21, 2023