Convalescent Plasma Donation Form

Convalescent Plasma Donation Form
First Name *
Last Name *
Are you between 18 and 69 years of Age? *

Yes No
Thank you for your interest in donating plasma. You must be between the ages of 18 and 69 to donate.
Phone Number *
May we text you? *

Yes No
Email
City *
State *
Zip Code *
Did you have COVID confirmed by a lab test? *

Yes No
Have you received any dose(s) of the COVID-19 vaccine? *

Yes No
If yes, what was the date of the first dose? *

Month Day Year
Date
What date was your positive test performed on?

Month Day Year
Did you have symptoms (for example, cough, shortness of breath, or fever)? *

Yes No
What date was date of your last symptoms?

Month Day Year
You will need to provide a copy of your COVID-19 test results. You can save time by uploading them here. (Optional)

Browse Files

Cancel of
How did you hear about our program? (Select all that apply)

Grifols website/Google Search Currently a donor Called or visited Donor center, saw poster Received a text / email from us Grifols plasma Facebook / Instagram / LinkedIn Facebook/IG other of friend FB/IG/TV - The fight is in US (the Rock or others) Via Grifols employee Health Department Hospital, doctor or nurse Another donor Family, partner, friend, co-worker (not a donor) Local news (TV, radio) LabCorp or other testing site
Please verify that you are human *
Should be Empty: