American Bone Marrow Donor Registry #__________________
CONSENT FORM
I am voluntarily furnishing blood to the American
Bone Marrow Donor Registry (ABMDR) for the purpose of determining my HLA type
for compatibility comparison as
a possible marrow or stem cell donor, or
I am submitting my HLA type information for recording in the
American Bone Marrow Donor Registry files. I understand
the need for and the process involved in marrow or stem cell donation. I hereby
grant the ABMDR permission to enter my information and HLA
type in its files and to include my HLA type only in Bone Marrow Donors
Worldwide to be compared to patients’ types in this
country and worldwide who are viable candidates for marrow transplantation. I further
understand that part of my blood sample
may be stored for the sole purpose of conducting further testing if I am
determined to be a possible
match with a patient. I understand
that such testing would not be performed without my signed consent. I further
understand that my name
will be kept confidential and not
released without my written permission.
I understand that the only side effects from the sample collection
might be some bruising or redness
at the site of the needle insertion.
Donor Name (Please Print)
Date ______ / /
Donor Signature Witness Signature
Donor Information
(Confidential)
Street Address Apt.#
City State
Zip
Phone Home(______) Work/Cell: (
)
Fax: (
)
__________________________Email:__________________________________________________
D.O.B. / / Sex Spouse First Name
Driver's License: State (_____ ) SS#___________________________________________
Above information used only
for the purpose of locating a donors' forwarding address or for cross-checking
donor records.
Ethnic origin: (may help in patient/donor matching due to the frequent occurrence of
some HLA antigens within certain ethnic groups.)
______Caucasian _______African American _______Native American ________Asian
________Hispanic/Latino
Other (specify) Specific
heritage (e.g French, Jewish, Korean)
_____________________________
Name and address of a relative
or close friend who could contact you if we are unable to reach you.
Name__________________________________________________ Spouse name_________________________
Address________________________________________________________ Apt#________________________
City State Zip________________
Phone Home(______)_____________________________ Work/Cell ( )___________________________
If you are
related to a particular patient, please note relationship and name
Patient Name:
_______________________________________
Relationship_____________________________
PLEASE COMPLETE APPLICATION AND MEDICAL QUESTIONNAIRE
IA0905