RESTRUCTURE AFRICA
LOVE AND PINT
Who has ever had a personal experience were blood was needed and someones live was at stake? Restructure Africa would be helping to save more lives through LOVE AND PINT initiative in partnership with Lagos State University Teaching Hospital (LUTH) and Lagos State Blood Transfusion Committee (LSBTC) on July 28th 2018 at Muri Okunola Park, Victoria Island Lagos. Our aim is to raise at least 1000 pints of blood which can save a minimum of 3000 lives. The main focus are patients living with sickle cell anaemia and different cancers. Would you like to be a donor? Kindly fill the form below. You can save 3 lives by your share of love. One pint saves 3 lives. All your information remains highly confidential and would be used for this purpose only.
Personal Information
Name
*
First Name
Last Name
Gender
*
MALE
FEMALE
Date Of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Occupation
Email
*
example@example.com
Address
*
Street Address
Local government area
City
State / Province
Postal / Zip Code
Blood Group
*
O+
O-
A+
A-
B+
B-
AB+
AB-
I DONT KNOW
Other
Genotype
*
AA
AS
SS
I DONT KNOW
Other
About Blood Donation
Have you ever donated blood before?
*
yes
no
If yes, when was the last time you donated?
1 month ago
3 months ago
6 months ago
A year ago
I can't remember
Other
Was there any complication after donation?
yes
no
What complication?
Health Status Check
your information remains confidential and shall be used for this purpose only.
Do you suffer any disease?(cardiac, bleeding disorders etc)
*
yes
no
If yes, please specify.
Do you have any allergies?
*
yes
no
If yes please specify
Are you on any routine medications?
*
yes
no
If yes please specify
Have you ever been screened for any of the infectious diseases? e.g HIV,HCV, HBV
*
yes
no
Consent
*
e.g I MRS AB, hereby agrees to donate blood............
For more enquiries
Instagram: @restructureafrica, Facebook: facebook/restructureafrica. Twitter: @RestructureA. Mobile contact: (+234)08022415847. Website: restructureafrica.org
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