Plasma Donation Medical Questionnaire Form
Please complete this form to help us determine your eligibility and readiness for plasma donation.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Current Weight (in kg)
*
Are you currently feeling healthy and well?
*
Yes
No
Have you had any cold, flu, or fever symptoms in the past 14 days?
*
Yes
No
Are you currently taking any medications?
*
Yes
No
Have you traveled outside the country in the past 3 months?
*
Yes
No
Are you available for a plasma donation appointment within the next two weeks?
*
Yes
No
Submit Medical Questionnaire
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