Schedule An Appointment

Returning Donor Contact Form


Returning donors please use this quick form to contact a LeukoLab representative to let them know you are ready for your next donation! Someone will then contact you directly to set up your next appointment depending on donation availability and your qualifications. Thank you!

Donor Info

* Please note, an answer to all items are required.

First Name:
Last Name:
Cell Phone:
 - 
Email Address:

Medical History:

Please answer as accurately as possible and note that our researchers sometimes look for donors with specific medical conditions as well.

Currently pregnant, or breastfeeding?
Yes No
Do you currently use blood thinners such as aspirin (such as for post heart attack, stroke or coronary interventions)?Yes No
Are you taking any other medication (prescription and/or over the counter)?
Yes No
Any known allergies to medications? Yes No

Have you ever been diagnosed with:

High Blood Pressure?
Yes No
High Cholesterol?
Yes No
Significant Anemia?
Yes No
Cancer?
Yes No
Diabetes?
Yes No
Blood Clot/
bleeding disorder?
Yes No
Sickle Cell Trait?
Yes No
Hepatitis/HIV?
Yes No
Skin disease diagnosed
by a physcian, such as
psoriasis or eczema?
Yes No
Autoimmune disorders ? Yes No

Do you have any conditions or disorders affecting major organs such as:

a. Brain
Yes No
Please specify:
b. Liver
Yes No
Please specify:
c. Lung
Yes No
Please specify:
d. Heart
Yes No
Please specify:
e. Kidney
Yes No
Please specify:
f. Thyroid
Yes No
Please specify:
g. Gastrointestinal
Yes No
Please specify:

What prompted you to donate again with us? *
Additional Comments:
*
Anti Spam Code:*

Please select whether you are a New LeukoLab Donor or a Returning Donor:

New Donor »    Returning Donor »