Convalescent Plasma COVID-19 Donor Registration Form

Thank you for your interest in convalescent plasma donation and joining our mission to save lives. Please complete and submit the form below if:

You have a lab-confirmed positive test for COVID-19 virus, OR a positive recovery test showing immunity
Your symptoms have been gone for at least 14 days
You meet the eligibility requirements to donate blood
You are willing to donate plasma

All information provided will be kept confidential and will only be used to qualify you as a donor.

IMPORTANT REMINDERS:

Documentation of a positive test is required to donate (can be provided upon submission of the below form)
Results must be a non-editable document (text messages will not be accepted)
Document must include your full name, testing facility or physician, test name, date, and result
When presenting to donate, donors are asked to bring and wear a face mask or face covering

Please complete and submit this form:

*Required fields

*Did you test positive for COVID-19?

Yes
No (Please do not submit if you did not test positive)

DOCUMENTATION OF A POSITIVE TEST IS REQUIRED TO DONATE

*What was your test date?

Please upload documentation from your healthcare provider that confirms your positive test result.NOTE: DOCUMENTATION MUST CONTAIN YOUR NAME; TESTING FACILITY OR MD NAME; TEST NAME, DATE, AND RESULT

*Have you received a COVID-19 vaccine (ex. Pfizer, Moderna, AstraZeneca)?

YOU MAY NOT DONATE CONVALESCENT PLASMA AFTER YOU HAVE BEEN VACCINATED.

*Have you received a convalescent plasma unit as part of your COVID treatment?

*Has it been at least 14 days since your last day of symptoms?

COVID-19 SYMPTOMS INCLUDE FEVER, COUGH AND SHORTNESS OF BREATH

Estimated date of last symptom:

*Name:

*Date of birth:

*Gender:

*Email:

*Preferred Phone Number:

If you were referred by an outside organization, please select referring organization:

If other, please enter referring organization:

*Please confirm: