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Address with Pincode
Aadhar Card Available?
Date of COVID-19 positive test
Name of Hospital
Date of Admission in Hospital
I Agree to share my details with iPlasma, which will Hospitals and Patients in need of Convalescent Plasma will have access to.
Date of Recovery
Do you have Discharge report from Hospital?
1. I confirm that the information I have provided in here is complete and accurate to the best of my knowledge.
2. I confirm that I fulfil the eligibility criteria for donors set out at www.iplasma.in.
3. I confirm that I wish to share the information provided in here with iPlasma or the exclusive purpose(s) of matching with patients from the database of patients registered with iPlasma and sharing this information directly and solely with the [matched patients and/or their next of-kin.
4. I agree to allow iPlasma for its use of the information for the exclusive purpose(s) set out above.