UTMB Blood Bank Donor Pledge Form

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Blood Donor Pledge Card

Thank you for your commitment to saving lives. Blood collected by UTMB gives the gift of life to patients at UTMB and Shriners Burns Hospital. Each unit of blood collected can save up to three lives. JUMP TO THE FORM

Donor Requirements

Must be in general good health.
Must have photo I.D.
Must be at least 17 years old.
Must weigh at least 110 lbs.
Should know the names and dosages of all medications being taken.
Should eat a healthy meal before donating blood.
Must not have donated whole blood in the past 56 days (8 weeks).

Why should I be a blood donor?

People in your community need your gift of life-- for the parent undergoing a transplant; for the car accident victim fighting for life; for the child with leukemia who needs a transfusion. These are only a few examples of the difference a blood donor can make.

For more information, call the UTMB Blood Bank at (409) 772-4861.

I pledge to Give for the Health of Texas by regularly donating blood at UTMB. The Blood Bank may contact me as follows:

Name:

Department:

Mail Route:

Address:

City:

State: ZIP:

Home Phone: Work Phone:

Cell Phone: Pager:

Email:

Fax/other:

I am interested in hosting a blood drive. Please contact me with more information.

I commit to donate whole blood:
two times/year
four times/year
six times/year

Call my relatives/friends to donate:

Name:
Phone:

Name:
Phone

Rather do this on paper? Download our printable pledge form as an Adobe PDF file.
(Need the Abobe PDF Reader? It's free.)

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