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Emergency Request

Request Blood

Fill out the form below. Be as accurate as possible - this information will be shown to potential donors to ensure a fast match.

All fields marked * are required. Your progress is automatically saved until you submit.

Patient Details

Information about the patient requiring blood

Total units required for the patient

Diagnosis, reason for transfusion, etc.

Contact Information

How donors can reach you

Bangladeshi number preferred (+880…)

Optional - alternate number

Optional

Optional

Optional

Hospital Details

Where and when blood is needed

Mark as Urgent

Enable if blood is needed within the next few hours.

Scheduled surgery or transfusion date

Blood Collecting Location on Map *

Search for the hospital or click on the map to drop a pin. District & Division will be auto-detected from the map pin.

Tap the map or drag the pin to adjust the exact location.

Additional Description

Any other information donors should know

Fields marked * are required.