Your Name

Your Age

Address

Gender
MaleFemale
Your Email ID

Your Mobile No.

Did you ever test +ve for Covid -19 Infection?
YESNO
Date of testing positive for Covid-19

What was your date of recovery?

Did you ever Donate plasma before if yes when?
YESNO

Your Blood group ?
A+B+A-B-AB-AB+O-O+
Do you suffer from any of the following diseases?
DiabetesBlood PressureLiver DiseaseLung DiseaseOtherNA
Do you consume Alcohol?
YESNO
Do you have an aadhar card ?
YESNO
Do you have discharge report issued by the hospital where you were treated ?
YESNO
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