Donor Identification - Clinical Research | Xera Med

Patient ID#

Donor Identification Verification Form

A. Donor Information

Name:

DOB:

Gender:

Race:

Caucasian - Not Hispanic

Black - Not Hispanic

Hispanic

Asian/Pacific Islander

American Indian/Native American

Other

Phone Number:

Email:

Street Address:

City/State/Zip:

B. Emergency Contact

Name:

Phone Number:

Email:

Relationship:

I verify the information provided on this document is true and accurate to the best of my knowledge.

Donor's Signature:

Please fill all the fields with correct values.