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Donor Prospect Registration

Thank you for your interest in the Blood and Plasma Research donor program. The following questions are designed only to give us an idea of whether or not your plasma could be rare and valuable enough to make it worthwhile for you and Blood and Plasma to pursue the possibility of your being a donor.

After reviewing your information, someone from Blood and Plasma will contact you to discuss further the possibility of your being eligible.

Although we will need more information if becoming a donor is a significant possibility, all we need now is your first name and some method of contact (phone number or email address).

Name 
Age  (must be 18 years or older)
Mailing Address 
City, State, ZIP 
Email Address 
Phone Number 


Have you ever been told that you have a red cell antibody?
    Check if yes
    By whom?
    Which antibody (if known)?
Have you ever had a blood transfusion?
Check if yes:

If you are a female,
    How many pregnancies have you had?
    How many living children do you have?
    If you have had a hysterectomy, when?
    If you have had a tubal ligation, when?

    Have you had any miscarriages or problem pregnancies?
    Please explain:


Please give a brief résumé of your medical history.
(surgeries, diseases, ongoing medications, etc.)