COVID-19 Plasma Donor Form

COVID-19 Plasma Donor Eligibility Form

Tulane Medical Center, Tulane School of Medicine, and The Blood Center, are seeking people fully recovered form COVID-19 to donate plasma that will be used to help patients currently suffering from COVID-19.

If you would be willing to donate plasma, please call 504-321-1740 or fill out the form below and click 'Submit' to be contacted by a representative to determine your eligibility. Thank you for your generosity.

1. First Name *

Last Name *

2. Email Address: *

3. Preferred Phone Number *

4. Gender *

5. Address *

Address Line 2

City *

State *

Zip/Postal Code *

6. Was your COVID-19 diagnosis confirmed by a lab test, such as a nasal or oral swab?

If yes to a nasal or oral swab test, please provide test center name and location

7. Do you still have any symptoms from COVID-19?

(such as fever, cough and shortness of breath)

8. Has it been at least 14 days since the last time you had symptoms from COVID-19?

9. Date of last symptom

Year

Month

Day

10. Have you been tested for COVID-19 after your recovery to document that you no longer have the virus?

Yes

No

I don't know

If yes, please provide test center name and location

11. If you have been tested for COVID-19 at any point during your illness, do you consent that we contact your test center(s) on your behalf to obtain a record of this test(s)?