fbpx

Be The Cure Registry

(by Jeevan Stem Cell Foundation)

Registered Public Charitable Trust since 1995
Landline: +91 44 2826 3113 • Mobile: + 91 97908 97918 • Email: stemcell@jeevan.org • Website: www.jeevan.org

PLEASE FILL THE FORM IN CAPITAL LETTERS AFTER UNDERSTANDING THE DONATION PROCESS. YOUR COMMITMENT IS ESSENTIAL


















Please answer the following questions correctly

Have you donated Blood/Platelets in the past?
YesNo
If yes, how many times:
Have you been refused as a blood donor ?
YesNo
If yes, when:

Have you had any of the following illnesses in the past?

Bleeding Tendency
YesNo
If yes, when:
Cancer
YesNo
If yes, when:
Diabetes
YesNo
If yes, when:
Fits
YesNo
If yes, when:
Fainting attacks
YesNo
If yes, when:
Heart Disease
YesNo
If yes, when:
High BP
YesNo
If yes, when:
HIV/AIDS
YesNo
If yes, when:
Hepatitis/Jaundice
YesNo
If yes, when:
Malaria
YesNo
If yes, when:
Tuberculosis
YesNo
If yes, when:
Venereal Disease
YesNo
If yes, when:
Have you ever received blood Transfusion?
YesNo
If yes, when:
Do you take any Medicines regularly?
YesNo
If yes, when:
Have you had any surgery?
YesNo
If yes, when:

Informed Consent

I hereby consent to provide a blood sample / buccal swabs / saliva in order to carry out HLA typing. I transfer the ownership of the blood sample / buccal swabs / saliva to Jeevan Stem Cell Foundation. I have been informed by Jeevan Stem Cell Foundation that after HLA typing of my blood sample / buccal swabs / saliva it will be included into the database.I understand that the HLA data will be used for analysis and publications to find ways to improve easy access to matching stem cells for patients with blood cancers and thalassemia.

  1. I have given consent to be a voluntary peripheral blood stem cell donor.
  2. I confirm the correctness of my personal data above and I agree that it is stored at Jeevan Stem Cell Foundation in order to search for donors.
  3. Collect and store the details on this form along with HLA typing of my blood sample / buccal swabs/saliva.
  4. Release necessary personal and genetic information (no names) to affiliated national and international bone marrow donors registries for the purpose of matching with potential bone marrow transplant recipients.
  5. I will make myself available for confirmatory tests when required.
  6. I will keep Jeevan Stem Cell Foundation updated about any change in my contact details.
  7. I agree to being contacted by Jeevan Stem Cell Foundation through the mobile and / or email.
  8. I have the option to change my mind about being a voluntary donor at any time.