COVID-19 Convalescent Plasma Donation Application Form

Thank you for your interest in our Convalescent Plasma Donation Program!

You are eligible to donate Convalescent Plasma if you:

  • Had a positive test
  • Had symptoms but are symptom-free for at least fourteen (14) days
  • Did not receive a convalescent plasma, red blood cell, plasma or platelet transfusion in the past three (3) months
  • Qualify as a volunteer community blood donor –  click here for General Eligibility Guidelines

You are NOT eligible to donate Convalescent Plasma if you: 

  • Received a COVID-19 vaccination
  • Received a convalescent plasma, red blood cell, plasma or platelet transfusion in the past three (3) months
  • Currently have symptoms or have not been symptom free for at least fourteen (14) days

While Convalescent Plasma is not a proven treatment, it is possible that this unique plasma, which is taken from individuals who have recovered from COVID-19 and have special antibodies against the virus, can aid in the treatment of critically ill coronavirus patients.

  • If you had a positive COVID-19 test result AND
  • Your symptoms have been gone for 14 days AND
  • You are willing to DONATE your plasma, please complete and submit the application below 

Xx
By completing the following application and attaching a copy of your test results, you are confirming
that you have been symptom-free for at least 14 days.  All information provided below is kept
strictly confidential, and will only be used to qualify you as a Convalescent Plasma donor. 

If you are determined to be eligible for the Convalescent Plasma program, a member of our
Medical Staff will contact you to answer any questions you may have,
and assist in scheduling your donation
at one of our six (6) locations. Please remember to bring a face mask to wear during your donation.

 

COVID-19 Convalescent Plasma Donation Application Form

  • Accepted file types: jpg, png, pdf.

To download, print and return this form and test result via mail, click here.


– COVID-19 convalescent plasma has not been approved or licensed by the FDA; 
– COVID-19 convalescent plasma has been authorized by the FDA under an EUA; 
– COVID-19 convalescent plasma is authorized only for the duration of the declaration that circumstances exist justifying the authorization of the emergency use of drugs and biological products during the COVID-19 pandemic under section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.