Walk-in-3 | B Positive Plasma

Are you allergic to iodine (shellfish) *

Emergency Contact Name *

Emergency Contact Phone *

Acknowledgements

I acknowledge that I am required to provide a valid Photo ID, proof of my full social security number and proof of my current address (if my current address is not listed on my photo ID) *

I acknowledge that I am required to eat a large healthy meal within 2 hours of my first donation appointment and be well hydrated. *

I acknowledge that the information provided on this form is to the best of my knowledge is the correct and current information for the individual listed on this form and that the individual is also aware of the acknowledgments listed below in order to be fully prepared for their donation. *

Please set a password for your donor account.*

Please Confirm a password for your donor account.*