Welcome to Physicians Plasma Alliance

Opening Hours : Monday to Friday 9am-5pm
  Contact : 1-877-637-5276

Pre-screening

Pre-Screening Form

Please fill out the pre-screening form below to determine your qualifications for PPA’s donor programs.

Click on the following list to indicate your diagnosis

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rightlogo1Donor Requirements

  • ok  You must be clinically diagnosed by a medical professional. Documentation of the diagnosis and/or treatment may be required.
  • ok  You must have a photo ID and be able to provide your social security number or proof of citizenship.
  • ok   You must be at least 18 years old.
  • ok   You must weight at least 110 lbs.
  • ok   You must disclose if you have ever been diagnosed with Hepatitis C and/or HIV.
Acute Specialty Antibodies List

Chagas DiseaseDengueGonorrhea/SyphilisHepatitis A/Hepatitis BHerpes Simplex Virus 1/Herpes Simplex Virus 2Lyme Disease/Barrelia burgdorferiMononucleosis/Epstein BarrToxoplasmosisVaricella zoster (Chicken Pox)Other (Describe in Message Box)

Chronic Specialty Antibodies List

AllergiesDiabetesMelanomaMultiple MyelomaOncologyRheumatoid ArthritisThyroid DiseaseOther (Describe in Message Box)

1. Are you currently being treated by a healthcare professional for this condition?

2. When were you diagnosed for this condition ?

3. Have you been prescribed any medication for this condition ?

4. If yes, describe your medications:

5. Are you experiencing any symptoms from your condition?

6. Have you recently had lab work to confirm your diagnosis?
YesNo

7. If yes, please email to , fax to (423) 477-3164, or upload the file here:










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8. Have you ever been diagnosed with (check all that apply):

Contact Information

First Name:
Last Name:
DOB:

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