| Giving Blood - Platelet Pheresis Enrollment Form |
|
Print this page and then fill it out and mail to the address at the bottom of the page.
| Name | Date | ||
| Address | |||
| City | State | Zip | |
| Soc. Sec. No. | DOB | ||
| Home Phone |
Business Phone |
Family Doctor |
|
| If you are protected by a Blood Bank of Delmarva membership, please specify membership name and number. | |||
| Membership Name |
Membership Number |
||
| Have you ever given blood before? [ ] Yes [ ] No | |||
| Have you ever been a platelet donor? [ ] Yes [ ] No | |||
| When are you available for donation? | [ ] Anytime [ ] 8:00am to 5:00pm [ ] 5:00pm to 9:00pm [ ] In Christiana [ ] In Dover |
| How much notice would you like before donation? |
[ ] Half-day [ ] One day [ ] More than one day notice |
| How often would you like to donate? | [ ] Twice a month [ ] Once a month [ ] Other (specify) _________ |
| Blood type | Signature |
Note: This is NOT a Blood Bank membership enrollment form.
Mail this form to:
Blood Bank of Delmarva
Christiana Center
100 Hygeia Drive
Newark, DE 19713