VISAKHAPATNAM BLOOD DONORS CLUB
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Patient's Name
*
First
Last
Date of Birth
*
Patient's Phone Number
*
Patient's Email Address
*
Sex
*
Male
Female
Other
Hospital Name
*
Referred by (Doctor)
Blood Group
*
O+
O-
A+
A-
B+
B-
AB+
AB-
WBC Count
Platelets Count
Required Blood Components
Therapeutic/Surgery
Yes
No
No. of Units required
Contact Person's Name
*
Address Person's Platelets
Contact Person's Phone Number
*
Contact Person's Email Address
*
Contact Person's Address
*
Relation with Patient
*
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