Name
Email
Phone
Cell Phone
Civil Status
Married
Sing;le
Place of Work or (retired)
Town You Live in :
Have you traveled outside panama in last 3 months
Yes
No
Have you had Covid-19 in last 3 months
Yes
No
Date of Last Blood Donation:
Cedula or Passport
Sex
Male
Female
Birth Date
Current Health Status
Normal
In Treatment
Blood Type
A
B
AB
O
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