Platelet Donation Interest and Screening Form
Thank you for your interest in donating platelets. Please complete the Platelet Donation Interest and Screening Form to help us determine your eligibility and contact you about future donation opportunities.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Have you donated platelets or blood before?
*
Yes, platelets
Yes, whole blood
No, never donated
Do you know your blood type?
A+
A-
B+
B-
AB+
AB-
O+
O-
I'm not sure
Have you traveled outside the country in the past 12 months?
*
Yes
No
In the past month, have you had any illness, fever, or infection?
*
Yes
No
Are you currently taking any medications?
Yes
No
Please share anything else we should know about your interest in platelet donation (optional)
Submit Interest
Should be Empty: