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Neighborhood Donor Center Special: Donate at a Neighborhood Donor Center May 18 through 21 and receive 200 additional points.

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Update Your Record

If you are a registered donor, we thank you for you commitment to helping patients. It is very important the information in our files is updated and accurate. Otherwise it may not be possible for us to contact you in case your blood typing matches that of a patient in need of a marrow transplant.

You may withdraw from this volunteer program at ay time, and if you do, we ask that your notify us immediately so that we can remove your information from our files.

Update Your Record

Fields marked with an asterisk (*) are required.

Please select which applies:

Update My Information
Remove Me From The Registry
E-Mail Address:
Name:
Did you register under a different name? Yes No
If yes, what was your former name?
Street Address:
City:
State:
ZIP Code:
Date of Birth:
Home Phone:
Work Phone:
Cell Phone:
Alternate contact name and phone number (Not residing at same address)
Have you had any other changes in your health since you joined the program? Yes No
If yes, please explain
Are you at an increased risk for infectious diseases? Yes No
If yes, please explain
Are you taking any medications? Yes No
If yes, please list your medications
Do you have a history of respiratory disease, including asthma? Yes No
Do you take any medication(s) related to the respiratory condition? Yes No
If yes, please list your medications
Do you have a history of heart disease? Yes No
Do you take any medications related to this heart condition? Yes No
If yes, please list your medications
Do you have a history of cancer? Yes No
If yes, please explain
Have you ever had neck, back, spine, hip or disc problems? Yes No
Have you had surgery in the past 12 months? Yes No
If yes, please explain
Are you pregnant or do you plan on becoming pregnant in the next 6 months? Yes No

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