Blood Donation Form

Full name Single line

First and last name of the donor for the registration record and donor ID lookup.

Date of birth Date picker

Used to calculate age eligibility against the 18 to 65 regulatory band most blood banks operate under.

Gender Dropdown

Drives conditional logic for the pregnancy question and downstream deferral rules.

Email address Email + verification

Paired with email verification so the autoresponder, slot reminder, and post-donation thank-you all reach a real inbox.

Phone number Phone

Mobile for day-of reminders, deferral notifications, and emergency contact during the draw.

Address Multi-line

Full postal address for record-keeping and deferral mapping when a region-specific travel restriction kicks in.

Blood type Dropdown

A+, A-, B+, B-, AB+, AB-, O+, O-, or "Don't know" so first-time donors can register without a prior test.

Weight Number + conditional

Conditional logic flags under-50kg donors with a "you may not be eligible today" message so the front desk catches the deferral before the draw.

Last donation date Date

Used to enforce the 56-day gap most regulators require between whole-blood draws.

Current medications Long text

Free-text list of prescription and over-the-counter medications so the clinician can flag any incompatibility before the draw.

Recent illness or surgery Yes / no + conditional

A "yes" answer reveals a follow-up text box for the condition and date so the screening team has the full picture in one read.

Travel in the last 12 months Yes / no + country

A "yes" answer reveals a country field so the team can apply the right deferral window for malaria, vCJD, and other region-specific risks.

Tattoo or piercing in the last 4 months Yes / no

Standard infection-control deferral question; a "yes" defers the donor for the regulator-mandated window.

Pregnancy in the last 6 months Conditional yes / no

Appears only when gender is not male. Captures the post-partum deferral window without asking irrelevant questions.

Preferred donation date and time Scheduler

Drop in the scheduler field so donors pick a slot from the available draws and the form auto-closes that slot the moment it fills.

Consent and digital signature E-signature

Donor signs on-screen with a finger or mouse. The signed electronic signature is timestamped, stored with the submission, and emailed back to the donor as a PDF.