Raktsankalp

🩸 Blood Donation Slot Booking Form

1. Full Name

2. Age

3. Gender

Male Female Other

4. Mobile Number

5. Email Address (optional)

6. Blood Group

7. Preferred Date for Donation

8. Preferred Time Slot

9. State

10. District (Uttar Pradesh)

Pincode

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11. Have you donated blood in the last 3 months?

Yes No

12. Are you currently on any medication?

Yes No

13. City / Location

14. Additional Notes (optional)

🛡 Your information will be kept confidential. We’ll contact you for confirmation.