Convalescent Plasma Donor | Baylor Scott & White Health

Please provide the name of the lab or facility that performed the test. Baylor Scott & White Health facility
Other

What was the date of your lab test?

Note: You will be required to provide documentation supporting your lab diagnosis. Should you be unable to provide this documentation, you will not be permitted to donate convalescent plasma.

If necessary, do you give Baylor Scott & White Blood Center medical staff permission to access your electronic medical record (EMR) to obtain proof of your lab diagnosis? Yes, I give Baylor Scott & White Blood Center medical staff permission to access my EMR for the purpose of confirming my lab diagnosis of COVID-19
No, I will provide documentation

Do you currently have symptoms?
Yes
No

Has it been at least 14 days since the last day of your symptoms? Yes
No

What was the last date of COVID-19 symptoms?

Note: If you did not experience symptoms, please use the date of your positive test.

Did you recieve a transfusion of COVID convalescent plasma during your treatment? Yes
No

FEMALES ONLY: Have you ever been pregnant, or are you pregnant now? Yes
No
N/A - I am MALE

Note: Females with a history of pregnancy will need to undergo additional testing in order to donate plasma.

First Name

Last Name

Phone Number (xxx-xxx-xxxx)

Email Address

Date of Birth (mm/dd/yyyy)

Note: You must be at least 17 years of age to donate convalescent plasma.

Convalescent Plasma Donor Program

Baylor Scott & White Blood Center