Autologous Blood Donation Eligibility Form
Please complete this form to help determine your eligibility for autologous blood donation. All questions are required for eligibility screening. Do not include sensitive personal or financial information.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Purpose and Timing of Donation
*
Please Select
Scheduled surgery (within 30 days)
Scheduled surgery (in more than 30 days)
Other medical procedure
Other
Blood Type (if known)
*
Please Select
A+
A-
B+
B-
AB+
AB-
O+
O-
Unknown
Do you have any of the following medical conditions?
*
Heart disease
Bleeding disorders
Active infection
None of the above
Are you currently taking any medications?
*
Yes
No
Have you experienced any illness or infection in the past 2 weeks?
*
Yes
No
Have you had any recent surgery, travel outside the country, or exposure to infectious diseases in the past 3 months?
*
Yes
No
Have you donated blood in the past 3 months?
*
Yes
No
Submit Eligibility
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