Donor Medical History Questionnaire

Donor Medical History Questionnaire

Please fill out this form as completely and accurately as possible. The information will be reviewed by our medical team. If you qualify for this study, you will be contacted to discuss donation options and scheduling.
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number*
Date of Birth*

MonthDayYear
What is your sex?*

MaleFemale
May we contact you by text message?*
At this time we are only collecting mobilized collections from male donors due to additional testing requirements and risks of the mobilization process in females. Non-mobilized and whole blood donations are still available. Please continue to fill out this form to see if you are eligible.

LifeSouth Research Institute collects certain personal health information when you donate mononuclear cells. This information is necessary for identification purposes, safeguarding the blood supply, recruitment, testing and follow-up activities, and other donation-related activities that may be necessary for research purposes, medical purposes or required by law. LifeSouth Research Institute respects the confidentiality of your health information, subject to the necessary uses described herein, and will protect the privacy of your information to the best of our ability and to the extent required by law.

Only authorized and trained individuals may access your personal health information. In rare cases, release of information may be required by federal or local authorities, such as the Food and Drug Administration (FDA). If you complete a donation, deidentified information from this questionnaire may be provided to research or commercial entities in such a manner that your identity cannot be determined.

LifeSouth Research Institute may contract with third parties for review of your medical history and information to determine eligibility for collection. Your information may be shared with such third parties to ensure your safety and qualification for collection protocols. You may be contacted by a third party, such as LifeSouth Community Blood Centers, regarding your donation.

I give my express permission to LifeSouth Research Institute and applicable third parties to review my submission and contact me about the content therein. I understand that my personal and medical information may be stored on a password protected secure cloud service that is compliant with all Health Insurance Portability and Accountability Act (HIPAA) regulations.

By signing below, I attest that I have completed this form truthfully and to the best of my knowledge.
Name*
Today's Date*

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Signature*

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