Prospective Plasma Donor Submission Form
PlasmaLab International | Everett WA

 
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Current Plasma Donation Programs - Please check one or more of the boxes below that apply to you. PlasmaLab is currently only looking for people with one or more of these specific conditions listed below.

 I have been medically diagnosed by a physician as a carrier of one of the following RARE Antibodies: anti-Wra, anti-Fyb, anti-Fya, anti-C, anti-E, anti-Kell, anti-K (Cellano), anti-Luca, anti-Dia. *Please note: The listed antibodies are extremely rare - if you have NOT been medically diagnosed by a physician as a carrier of one of these antibodies, please do not mark this box. 

I am interested in PlasmaLab's Allergy Research Program because I experience allergies to:

I have allergy testing results available for review. (Note: previous testing results are helpful, but not necessary, for acceptance into PlasmaLab's Allergy Research Program.)

What food/spices do you experience allergy symptoms to? Please describe your symptoms.

I have experienced anaphylaxis to foods/spices.

I have experienced anaphylaxis within the past 10 months to a medication.

What medication did you experience an anaphylactic reaction to? When did you experience this reaction? Please describe the reaction.

I have experienced anaphylaxis within the past 10 months to an insect bite or sting.

What insect bite/sting did you experience an anaphylactic reaction to? When did you experience this reaction? Please describe the reaction.

I am interested in PlasmaLab's Autoimmune Disease Research Program because I have been medically diagnosed with:

Please list the autoimmune condition(s) you have been medically diagnosed with:

Please indicate the Red Blood Cell Antibody you carry:

Please contact our office at 425-258-3653 if you'd like to participate in Infectious Disease Research. Donors for this program must donate plasma within 7 to 10 days of the first symptoms of the disease. Test results from your medical provider may be requested as confirmation of diagnosis.

Please contact our office at 425-258-3653 if you'd like to participate in Lyme Disease Research. Donors for this program must donate plasma within 7 to 10 days of the first symptoms of the disease. Test results from your medical provider may be requested as confirmation of diagnosis.

Did your medical provider perform Immunocap testing to confirm a diagnosis of Alpha-gal Syndrome?

Have you had a screening appointment at PlasmaLab before?

Have you donated plasma at PlasmaLab before?

Were you referred to us by someone?

Person/Doctor who referred you:

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How did you learn about PlasmaLab?

Would you like to schedule a 30-minute appointment to be screened for PlasmaLab's Research Program?

Are you willing to donate plasma two or more times if accepted into PlasmaLab's Research Program? (Please note: weekday appointments only.)

Questions and Comments

Terms and Conditions Agreement

PlasmaLab will contact you with details about our antibody research program(s). PlasmaLab will make every effort to safeguard your information and will not share, sell, or allow access to this information with anyone.

Referral and donor compensation will be issued upon qualification, acceptance, and completion of one plasma donation for our allergy or autoimmune program. To learn more about our donor qualifications please click here.

Our complete list of conditions may be accessed in our Privacy Policy