Convalescent Plasma COVID-19 Donor Registration Form

Thank you for your interest in convalescent plasma donation and JOINING OUR FIGHT TO SAVE LIVES.

While COVID has no proven treatment, it is possible that plasma taken from those who have recovered (convalescent plasma), which has antibodies against the virus, could help.

Please submit the form below if you meet the following criteria:

Lab confirmed positive test for COVID-19 (documentation of a positive test is required). All types of positive tests are accepted, including a positive antibody test.
Your symptoms have been gone for 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. All types of positive tests are accepted, including a positive antibody test.
Documentation must include your full name, testing facility or physician, and date of test.
When presenting to donate, donors are asked to bring a face mask or face covering.
Please only submit this form one time. Once you submit the form, you are in our database and we will contact you to schedule your first and future CP appointments.

Versión en español del formulario

CP Donor Registration Form:

* Required fields

* Did you test positive for COVID-19?

Yes
No - If you did not test positive for COVID-19 or do not have a positive antibody test result please do not submit this form

DOCUMENTATION OF A POSITIVE TEST IS REQUIRED TO DONATE.

* What was your test date?

* Please upload documentation from your health care provider that you tested positive.DOCUMENTATION MUST INCLUDE YOUR FULL NAME, TESTING FACILITY OR MD, AND DATE OF TEST.

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

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

* Estimated date of first symptom:

Estimated date of last symptom:

* First Name:

Middle Initial:

* Last Name:

* Date of Birth:

* Email:

* Preferred Phone Number:

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

If other, please enter referring organization:

* Please verify:

COVID-19 and Blood Donation

Convalescent Plasma COVID-19 Donor Registration Form

CP Donor Registration Form: