Reinstatement Form

Thank you for your interest in donating blood and helping to save lives! Please complete the following reinstatement form if you were:

Previously deferred from giving blood at Blood Bank of Hawaii
or
You were told by Blood Bank of Hawaii that you were ineligible due to a deferral that was applied to your donor record

*You will be contacted once your reinstatement has been completed.

Note: If you have never donated at Blood Bank of Hawaii, please check our donor eligibility information page and make an appointment if you are eligible.

*Required

Full Name*
List any other names you may have used during previous blood donations (or attempts to donate) at Blood Bank of Hawaii such as: nicknames, maiden names, prior married names, etc.
Date of Birth*
MM slash DD slash YYYY
Email Address
Contact Phone Number*
CURRENT FULL ADDRESS*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Reason for your deferral (if unknown, enter 'Unsure')*
Donor ID # (IF KNOWN)
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Phone
This field is for validation purposes and should be left unchanged.