Schedule An Appointment - New Donor

All potential donors are screened to see if they are eligible to participate in LeukoLab's donation options. Donors will follow the easy 3 step process below prior to donation.

Donor Screening Process

Contact LeukoLab using the screening form below for quickest response. Please note it may take up to 2 weeks to hear from us; please be patient! We see many donors at a time and promise to get to your request shortly.

Step 1 - Complete a Donor Screening Form here to begin the process.


Step 2 - If preliminary eligibility is met, LeukoLab will schedule an on-site health screening. We will measure weight, blood pressure and pulse and obtain blood samples to determine full donation eligibility. During this visit you will read, complete screening consent and donation information documents. You will not donate at this appointment.


Step 3 - A LeukoLab representative will inform you if you have met eligibility requirements for any or all of the Donation Options. Once you agree to participate, we will confirm your availability and contact you for a donation. You are ready to donate!

There is no compensation for the screening process.

New Donor Screening Form


Basic Info

Availability:

A majority of LeukoLab donations take place Mon-Thur 7:30am – 1pm and at times require less than 2 weeks notice to commit to a donation. Please confirm that your schedule can accommodate these times:

Yes – I confirm that my availability is within the LeukoLab donation schedule.
No – I am unavailable at these times however would like to be considered for special donations at other times.

Location:

All donor must live within one hour of a LeukoLab facility. Do you live within one hour of 1301 Harbor Bay Parkway, Alameda, CA 94502 or 500 Congress Street, Quincy, MA 02169?

Yes – I confirm that I live within 1 hour of a LeukoLab facility (or at least travel to the area on a regular basis). For verification my physical address is:





No – I do not live within 1 hour of a LeukoLab facility.

SSN:

Are you a U.S.citizen with a SSN? Please note: Non-US citizens are not eligible to donate at LeukoLab.

Yes No

Donor Info

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

First Name:
Last Name:
DOB:
Gender:
M F
Cell Phone:
 -   - 
Height:
ft  in
Weight:
lbs
Ethnicity:
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 smoke or chew tobacco products?
Yes No
Approximately how much alcohol do you consume per week?
DRINKS/WEEK
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
Do you take food or vitamin supplements? Yes No
Any known allergies to medications? Yes No
Any known allergies to food? Yes No
Any known allergies to the environment (i.e. dust, pollen)? Yes No

Have you ever been diagnosed with:

High Blood Pressure?
Yes No
High Cholesterol?
Yes No
Anemia?
Yes No
Cancer?
Yes No
Diabetes?
Yes No
Blood clot/
bleeding disorder?
Yes No
Sickle Cell Trait?
Yes No
Hepatitis/HIV?
Yes No
Asthma?(Adult and/or childhood) Yes No
Skin disease diagnosed by a physcian?
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:
Any family members with a blood or bone marrow cancer (Leukemia, Lymphoma, Multiple Myeloma)? Yes No
If you have donated blood before, have you:
- donated blood in the past 8 weeks
Yes No
- ever experienced any of the following: difficulties in finding veins
Yes No
- fainting, or fear of needles?
Yes No
Please note this may disqualify you for donations if you are unable to donate Bone Marrow.
Have you been vaccinated for Hepatitis B with series of 3 injections?
Yes No Unsure
Have you had a tetanus shot in the last 10 years? Yes No Unsure
Have you had a flu shot? Yes No Unsure

Referred to LeukoLab by:
Additional Comments :
Anti Spam Code:

Start Here »

This will send your contact information to our staff and we will respond to you shortly in order to begin the screening process.

PLEASE NOTE: None of the information that we obtain from this screening will be disclosed to anyone other than the LeukoLab staff. The information will be kept confidential and will be password protected to help maintain confidentiality. Remember, your participation is voluntary and completing this donor screening does not obligate you to donate.

SIGN UP FOR LEUKOLETTER

News

  • 2016-03-01
    Free FitBit! Our 'super donors' are still eligible to receive a FREE FitBit Flex for donating a mobilized white blood cell collection from now until supplies last IN ADDITION to the normal donor compensation! Mobilized donations are in high demand from researchers so we want to encourage our healthy donors who have an interest to inquire about their eligibility today! Find out if you qualify and schedule an appointment today!
Untitled Document