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.

Please check all that apply:

	Update my contact information
	Remove me from the Registry I no longer want to donate marrow or blood cells. Complete and submit and information below if you wish to be removed from the registry.

Name:
Did you register under a different name? Yes No
If yes, what was your Maiden Name?
Street Address:
City:
State:
ZIP Code:
Date of Birth:
Home Phone:
Work Phone:
Cell Phone:
E-Mail Address:

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

Digital Donor

Neighborhood Donor Center Special

Update Your Record