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By submitting this survey, you are willing to be called upon to give blood if/when a need should arise. Blood donations at Anna Jaques are used to support our patients and community.

The information you share below will be used to determine if/when you will be called upon to donate blood based on your qualifications and the need for your blood type at any given time. Thank you for supporting the AJH Blood Donor Program! 

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* 1. Enter your last name.

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* 2. Enter your first name.

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* 3. Contact phone number (cell phone preferred).

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* 4. Enter your email address.

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* 5. What is your biological gender? 

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* 6. Select your height

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* 7. Enter your weight

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* 8. What is your blood type?

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* 9. If you don't know your blood type, would you be willing to do a quick blood test at Anna Jaques to find out?

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