Name

Email

Phone

Cell Phone

Civil Status Married
Single

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+ Pos
A- Neg
AB+ Pos
AB- Neg
B+ Pos
B- Neg
O+ Pos
O- Neg

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*er:

You Qualify If:

You are Between 18 and 65 years old

Minimum wight (110 lbs)

In good health

No Covid since May 1, 2022