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?
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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?
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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
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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
*
Submit
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