Plasma Donation Medication Deferral List Form
Please complete the following screening questions to help us determine if any medications you are taking may require a temporary deferral from plasma donation.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Have you taken any prescription or over-the-counter medications in the past 30 days?
*
Yes
No
Please select any medications you have taken in the past 30 days (select all that apply):
*
Antibiotics (e.g., Amoxicillin, Azithromycin)
Accutane (Isotretinoin)
Finasteride (Propecia, Proscar)
Dutasteride (Avodart)
Antiplatelet or anticoagulant drugs (e.g., Warfarin, Plavix, Eliquis)
Immunosuppressants (e.g., Methotrexate, Azathioprine)
Insulin or other diabetes medications
Growth hormone
None of the above
Other
If you selected 'Other', please specify the medication(s):
When did you last take any of the medications listed above?
-
Month
-
Day
Year
Date
What was the reason for taking the medication(s)?
Are you currently under a healthcare provider’s care for any ongoing medical condition?
*
Yes
No
Have you been advised by a healthcare professional to temporarily delay or avoid blood or plasma donation?
*
Yes
No
Is there anything else related to your recent medication use or health that could affect your eligibility to donate plasma?
Submit
Should be Empty: