We request the friends/relatives of the patient in need of blood to give the following details, so that, in the event of not getting suitable donors, we may post your request , in the bulletin board .
| Your Name | |
| (Optional) Email ID | |
| PATIENT INFORMATION | |
| Patient Name | |
| Age | Years |
| Sex | Male Female |
| City | |
| State / Province | |
| Country | |
| Blood Group | |
| Others | |
| Rh | |
| Hospital Admitted in | |
| Room No. | |
| Requirement | Urgent Before |
| For What Purpose | |
Urgent requirements are automatically posted in EMERGENCIES. Volunteers may contact you.
I UNDERSTAND THAT THE DETAILS FURNISHED ABOVE ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I ALSO UNDERSTAND THAT THE SITE SHALL NOT BE HELD RESPONSIBLE FOR ANY DEFECT /OR FALSE INFORMATION THAT MIGHT HAVE BEEN GIVEN BY THE USERS OF THE SITE. I AM SEEKING INFORMATION FROM THIS SITE ONLY WITH A GENUINE REQUIREMENT OF BLOOD AND THERE IS NO OTHER ULTERIOR MOTIVE OF MAKING ANY MONETORY OR ANY OTHER BENEFIT.