Covid Plasma Donation
Thank you for your interest. A member of our team will reach out if you are a candidate for the program.
Donor Information
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Age
Gender
Male
Female
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Blood Type
Type O
Type A
Type B
Type AB
I don't know
Was your COVID-19 diagnosis confirmed by a lab test?
Yes
No
Do you currently have symptoms?
Yes
No
Date of last symptoms (approximate):
-
Month
-
Day
Year
Date
Have you had a follow up test that was negative for COVID-19
Yes
No
Signature
Clear
Submit
Should be Empty: