b donors
DESCRIPTION
JLZCHLCTRANSCRIPT
SKMT BLOOD DONORS CLUB MEMBERSHIP FORMMRD/SBDCMF/R/08
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Marketing & Resource Development DepartmentSKMT Blood Donors’ Club
Membership Form
PERSONAL DETAILS
Name:…………………………………………………………………….………Father’s Name:………………………………………………………………………………….………
College/workplace address: ………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………….………………… Tel:………………………...........................................…..
Home address:……………………………………………………………………………………………………………………………………………………………………………………
Tel: ……………………………………………………………………… Mobile:…………………………………………………………………….……
E-mail: ……………………………………………………………….
Date of Birth: …………………………………………………….. Gender: Male Female
NIC # …………………………………………………………....…….
Blood Type: (Please encircle)
A POSITIVE A NEGATIVE B POSITIVE B NEGATIVE
O POSITIVE O NEGATIVE AB POSITIVE AB NEGATIVE
If you are not aware of your blood group, please visit our Blood Bank to donate a unit of blood and get your Blood Group Card.
What is the best way to contact you? Home Telephone Mobile E-mail
What is the best time to contact you?Weekdays (Mon-Sat) From…………..To…………….Weekend / Holidays From…………..To…………….
Signature: ………………… Date: ……..
I voluntarily register myself and authorize SKM BLOOD DONORS Club to contact me for Blood/Blood Component donation as and when desired for any patient undergoing treatment at the hospital.All information will be kept confidential
TO BE FILLED IN BY SKMCH&RC OFFICE ONLY:
Membership No: ………………………….………… Date: ……………………………………………..…… Signature: ………………………….………
Shaukat Khanum Memorial Cancer Hospital & Research Centre7-A, Block R- III, Johar Town, Lahore
Tel: +92 42 3 5945100 Ext. 2366, 2404E-mail: [email protected]
Retention Period: 10 Years Filing Location: Marketing & Resource Development Department