C.P. Plasma Center, Inc. (CPPC)

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Thank you for your interest in the C. P. Plasma Center, Inc. (CPPC) donor program. The following questions are designed only to give us an idea of whether or not your plasma could be rare and valuable enough to make it worthwhile for you and CPPC to pursue the possibility of you being a donor.

After reviewing your information, someone from CPPC will contact you to discuss further the possibility of you being qualified.

Although we will need more information if becoming a donor is a significant possibility, all we need now is your first name and some method of contact (phone number or email address).

Name
Age	(must be 18 years or older)
Mailing Address
City, State, ZIP
Email Address
Phone Number

Have you ever been told that you have a red cell antibody?

Check if yes

By whom?
Which antibody (if known)?

Have you ever had a blood transfusion?
Check if yes:

If you are a female,

How many pregnancies have you had?
How many living children do you have?
If you have had a hysterectomy, when?
If you have had a tubal ligation, when?

Have you had any miscarriages or problem pregnancies?
Please explain:

Please give a brief résumé of your medical history.
(surgeries, diseases, ongoing medications, etc.)