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Plasma Donation


LifeBridge Health is looking into whether antibodies in blood from those who have recovered from COVID-19 may be beneficial as potential treatment for some people who currently have the disease.
 
As part of this, LifeBridge Health is looking for those who have recovered from COVID-19 for a volunteer donation of blood plasma (also known as a convalescent plasma donation). 
 
LifeBridge Health is partnering with the American Red Cross to coordinate these plasma donations, as well as following the FDA-approved protocol for plasma donation and treatment.
 
Those who may be interested should fill out this web form, and someone from our team will contact you.

Your information will only be used by LifeBridge Health, consistent with HIPAA regulations and the LifeBridge Notice of Privacy Practices.

If you are interested in donating plasma, please complete the questionnaire below.

Have you ever donated blood before?
Antiplatelet agents
  • (Feldene/Prioxicam) within the last 2 days
  • Effient/prasugrel within the last 3 days
  • Brilinta/ticagrelor within the last 7 days
  • Plavix/clopidogrel within the last 14 days
  • Ticlid/ticlodipine within the last 14 day
  • zontivity/vorapaxar within the last 1 month

Anticoagulants or “blood thinners”
  • Arixtra/fondaparinux within the last 2 days
  • Eliquis/apixaban within the last 2 days
  • Fragmin/dalteparin within the last 2 days
  • Lovenox/enoxaparin within the last 2 days
  • Pradaxa/dabigatran within the last 2 days
  • Savaysa/edoxaban within the last 2 days
  • Xarelot/rivaroxaban within the last 2 days
  • Coumadin, warfilone, jantoven/warfarin within the last 7 days
  • Heparin, low molecular weight heparin within the last 7 days

Acne treatments
  • Accutane, amnesteem, absorica, claravis, myorisan, sotret, zenatane/isotrtinoin within the last 1 month

Multiple myeloma
  • Thalomid/thalidomide within the last 1 month

Hair loss remedy
  • Propecia/finasteride within the last 1 month

Prostate symptoms
  • Proscar/finasteride within the last 1 month
  • Avodart Jalyn/Dutasteride within the last 6 months

Immunosuppresent
  • Cellcept/mycophenolate mofetil within the last 6 weeks

Basal cell skin cancer
  • Erivedge/vismodegib within the last 24 months
  • Odomzo/sonidegib within the last 24 months

Relapsing Multiple Sclerosis
  • Aubagio/teriflunomide within the last 24 months

Rheumatoid arthritis
  • Arava/leflunomide within the last 24 months

Hepatitis exposure
  • Hepatitis B Immune Globulin/HBIG within the last 12 months
Psoriasis
  • Soriatane/acitretin within the last 36 months
  • Tegison/etretinate EVER
  • Growth Hormone from human pituitary glands EVER
  • Insulin from Cows (Bovine or Beef insulin) manufactured in the United Kingdom EVER
  • Have you ever tested positive or been diagnosed with HIV, malaria, Chagas, babesiosis, cancer including leukemia, heart or lung disease or a bleeding condition or blood disease?
  • In the past 3 months have you had a new tattoo or piercing?
  • In the past two months have you had a vaccination?
  • Have you traveled to an area endemic for malaria in the past 3 months, spent more than 3 months in the UK between 1980-1996, spent more than 5 years in France or Ireland between 1980-2001 or ever receive a blood transfusion in the UK, France or Ireland?
  • Are you a male who has had sex with a man in the past 3 months?
  • Are you a female who has had sex with a man who has had sex with a man in the past 3 months?
  • Have you received money or drugs in exchange for sex or used a needle to take a drug not prescribed by a doctor.
  • In the past year, have you have had a blood transfusion, organ transplant, skin or bone graft procedure, accidental needlestick, risk of exposure to Hepatitis, been treated for a sexually transmitted disease, had sexual contact with someone with HIV or been in jail for more than 72 consecutive hours.


* Indicates required information
* First Name:



* Last Name:



* Email Address:



* Phone Number:




*City:



* State:



* Zip Code:



* Date of Birth: (mm/dd/yyyy)



* Blood Type:




 Gender



 If female, are you pregnant?



 If female, how many pregnancies have you had?



* What date did symptoms begin?:



*Have you tested positive for COVID-19?




If so, date of COVID test: (mm/dd/yyyy)



Which hospital/facility completed your COVID Test?:



Please check any symptoms that you had originally.


* When did you last experience COVID symptoms?: (mm/dd/yyyy)



* Do you still have symptoms




* Did a doctor tell you that you probably had COVID-19 but did not test you




* Were you symptomatic while living with a COVID-19 positive person?




* Were you symptomatic after direct contact with COVID-19 patients as a healthcare worker?




 If you have already registered with an out-of-town COVID plasma registry, please let us know which one


* Have you had a repeat COVID test?




 If so when: (mm/dd/yyyy)



 What were the results?



 Have you done antibody testing?



 If yes, what were the results?



* Are you a current patient of LifeBridge Health or one of its practices or hospitals.




* Have you ever donated to The American Red Cross?




* Authentication:

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