Please complete this form if you are interested in being a blood donor for Birmingham Quality.
We will contact you on receipt.
Birmingham Quality Blood Donor Registration Form
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indicates required fields
Title:
*
First name:
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Surname:
*
Date of birth:
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address line 1:
address line 2:
address line 3:
*
Town/City:
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Postcode:
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Home phone:
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Mobile phone:
*
email:
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preferred means of contact:
home phone
mobile phone
email
post
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Select all that apply:
I am in good health apart from my diabetes or haemochromatosis
I have been a blood donor in the past
I have diabetes (type 2)
I have haemochromatosis
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Short message to Birmingham Quality:
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Confirm willingness to donate:
Yes
No