Donor Application Form Please fill out the form below to apply as a StemExpress donor. Name* First Last Email* Enter Email Confirm Email PhoneZipcodeBirthdate MM DD YYYY HeightWeightDonation Type (Please check all that apply)* Unit of Blood Leukapheresis Bone Marrow All Disqualification QuestionsPlease read the following text to complete the question BELOW. If any of the following apply to you, check the "Yes" box. • Are you under the age of 17? • Have you ever been diagnosed with a heart condition or had heart problems? • Are you at risk of or have you tested positive for HIV (The AIDS virus)? • Have you ever been treated for abnormal bleeding? • Do you use illegal drugs? • Do you use pharmaceutical drugs for recreational use? • Are you pregnant? • Are you currently on any antibiotics? • Do you have a medical condition that makes it hard for your blood to clot?Disqualification (please check Yes or No)*YesNoDisqualifications (Bone Marrow Only) * Please read the following text to complete the question BELOW.If either of the following apply to you, check the "Yes" box. • Do you currently have neck, back, hip, or spine problems? • Have you ever had problems or complications with general or local anesthesia?Disqualification - Bone Marrow (please check Yes or No)*YesNoPlease Check all that apply in the question BELOW.If you have never had previous complications with donating, please choose the "N/A" box.Previous Donation Complications* N/A Anemic High Blood Pressure Other (please indicate in the box below) Other - (previous donation complications)Availability Monday Tuesday Wednesday Thursday Friday Best Time Morning Mid-Day How did you hear about us?*StemExpress WebsiteCraigslistFacebookEl Dorado County FairOther (please indicate in box below)Other - (how did you hear about us?)Referred by:
