Donate - Public Health Platform

Public Health Platform

Campaign Registration Form

Account Information

Name, Mobile Number and Email ID

Personal Details

Gender, Date of Birth, Blood Group & Address

COVID History

Past medical history of COVID

Completion

Provide your Consent and Submit

Mission COPE (COVID Plasma Endeavour)

Plasma Donation Pledge - Covid India Campaign

The information provided here in this Donation Pledge Form will be subjected to verification before one can donate their Plasma. Kindly keep the COVID Medical records ready for verification purposes.

Are you the Plasma Donor Or Are you filling the Plasma Donation Pledge on behalf of someone you know who has recovered from Covid-19?

Yes, I am the Plasma Donor No, I am filling the Pledge for someone I know who recovered from Covid-19. I hereby confirm that I have taken appropriate consent of the Plasma Donor to fill this donation pledge on his/her behalf.

Account Information

Please provide the below information to Register yourself

Your First Name*

Your Last Name*

Your Gender*

Your Email ID*

Your Mobile Number*

Secondary Contact Number*

OTP*

Personal Details

Please provide your personal details

Do you have any Kids?

Yes No

Age*

Blood Group*

Address*

City*

COVID History

Please provide your History on COVID

Have you donated plasma before?*

Yes No

If so, when? //

Approximate date when the Plasma Donor was first tested for COVID and found +ve* //

Completion

Please provide your consent to share your information and Submit to Complete

The information provided by you will is accessible by the below Organizations

The information provided by you shall be solely used for the purpose for which this form is being submitted.

HCG Cancer Care Center Hospital HCG Tower, # 8, P. Kalinga Rao Road, Bengaluru, Karnataka - 560027

SyMetric Service Provider No. 19, CA Site No. 1, HAL 3rd Stage, Bengaluru, Karnataka - 560008

HCG Cancer Care Center Hospital HCG Tower, # 8, P. Kalinga Rao Road, Bengaluru, Karnataka - 560027

Are you sure that the information provided here is Valid and that you provide your consent for your information to be used to create an Account on the Public Health Platform?*

Yes No