Bone marrow stem cell transplant for myeloma, hodgkins, leukemia, more. We do bone marrow stem cell transplant for myeloma and hodgkins. For myeloma and hodgkins, get bone marrow stem cell transplant.

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White Blood Cell Donor Reply Form

STEM CELL CANCER & REGENERATIVE MEDICINE RESEARCH, INC
Contact Information
Your Name
Phone
eMail
Date of Birth
Mailing Address
	By checking here you are authorizing that the South Florida Bone Marrow / Stem Cell Institute is using this information to determine your eligibility for the trial.
Instructions	Please fill out about contact information completely. Also, please respond to questions 1 though 7 by checking the appropriate answers. For additional information regarding this trial, please call the South Florida Bone Marrow / Stem Cell Transplant Institute research team at (561) 752-5522
What is your gender ? Male Female
What is your self-described race ? White Black Asian Other If other, please specify
What is your Blood Type ? A+ A- B+ B- AB+ AB- O + O - Don't Know
Have you donated blood or blood products in the last 12 months ? Yes No
Have you ever been deferred from giving blood ? Yes No If YES, please specify reason
Have you ever been diagnosed with cancer ? Yes No
Has any member of your family been diagnosed with cancer (Check all that apply) ? Primary relative (parent, brother or sister) Grandparent Aunts or Uncles Cousins Nieces or Nephews If you know the types of cancer, write it below :
Thank you!