HemaCenter Donor Lead Form

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Campaign ID
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WELCOME TO HEMACENTER
Get Paid to Save Lives

Did you know your white blood cells can make a big difference?

By donating these cells through a process called leukapheresis, you help scientists across the US and abroad advance therapies to fight diseases (such as cancer and diabetes) and save lives.

To qualify you as a potential donor, we need answers to the following questions. This form should take you no longer than 5 minutes to complete.

If you qualify, you can earn up to $300 for your first donation, and reliable repeat donors can earn up to $1500 per donation!!

You can earn $100 just by filling out this form and coming in for a pre-screen appointment!

PLEASE NOTE: Several factors could temporarily or permanently affect your eligibility to donate blood. These include certain health conditions, high or low iron levels, recent tattoos or piercings, certain medications, travel history, and certain sexual activities or history. Having a sexually transmitted disease or Hepatitis may also disqualify you. Additionally, if you have recently donated blood or plasma elsewhere, this may also disqualify you. In these cases, we will assess your eligibility and may or may not be able to draw your blood. If we are unable to draw your blood, you will not be compensated for your visit. If you have any questions or concerns about your eligibility, please contact HemaCenter prior to your appointment.

Thank you for your interest and your time.
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How did you hear about HemaCenter?* This field is required.
Search Engine (Google, Bing, etc.)
Friend/Family Referral
Social Media
Blog/Publication
Other
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Have you donated at HemaCenter before?* This field is required.
YesNo
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What was your sex at birth?* This field is required.
Female
Male
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Are you currently pregnant?* This field is required.
YesNo
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Are you currently breastfeeding?* This field is required.
YesNo
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What is your approximate weight?* This field is required.
Weight (Lbs)
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What is your approximate height?* This field is required.
Please Select
Please Select
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Feet
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Inches
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Do you currently smoke tobacco products? (Cigarettes, Cigars, or Hookah)* This field is required.
YesNo
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Have you been hospitalized within the last 12 months?* This field is required.
YesNo
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What were you hospitalized for?* This field is required.
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Have you tested positive for any of the following infectious diseases in the past 12 months?* This field is required.
HIV
Hepatitis
Syphilis
None
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Have you been in juvenile detention, jail or prison in the past 12 months?* This field is required.
YesNo
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When were you released from juvenile, jail or prison?* This field is required.
Date
Month
Day
Year
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Have you had any new tattoos, piercings, or other body modifications in the past 3 months?* This field is required.
YesNo
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When did you get this new tattoo, piercing or other body modification?* This field is required.
Date
Month
Day
Year
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Do you have any pre-existing medical conditions?* This field is required.
Cancer
Crohn's Disease
Lupus
Rheumatoid Arthritis
Celiac Disease
Diabetes
Multiple Sclerosis
Sickle Cell
Heart Disease
None
Other
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Are you currently taking any medications?* This field is required.
Amoxicillin
Aspirin
Azithromycin
Cephalexin
Ciprofloxacin
Clindamycin
Coumadin
Doxycycline
Metronidazole
Warfarin
None
Other
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Have you ever tested positive for COVID?* This field is required.
YesNo
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What is the approximate date of most recent COVID infection?* This field is required.
Date
Month
Day
Year
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Have you traveled outside the United States in the last 12 months?* This field is required.
YesNo
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Where did you travel to?* This field is required.
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Have you donated blood, plasma, or apheresis material (white blood cells) in the past 2 months?* This field is required.
YesNo
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Where did you donate blood, plasma, or apheresis material (white blood cells)?* This field is required.
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Have you received any vaccines in the last 12 months?* This field is required.
COVID Vaccine
Flu Vaccine
Pneumococcal/Pneumonia Vaccine
RSV Vaccine
None
Other
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What is your availability for donation?* This field is required.
Mornings (8am-12pm)
Afternoons (12pm-5pm)
Evenings (5pm-10pm)
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Date of Birth* This field is required.
Date
Month
Day
Year
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Contact Information* This field is required.
First Name
Last Name
Email (example@example.com)
Phone Number
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Date
Month
Day
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