Stem Cell - Prospective Donor Intake Form
Transplant Center

NOTE: This request form is for relatives of UVA Health patients only.
For all others, please access the website to become a National Registry Donor.

= required

Demographic Information

(legal name)
(II, III, Jr., Sr.)

Contact Information

Please, no P.O. boxes due to shipping method.

Please provide at least 1 phone number. *

Best phone number to reach you *

Medical History

Please note that it is important that you answer these questions honestly so that an appropriate, and safe, decision can be made about your candidacy for donor evaluation.

Female Donors Only: In the past 6 weeks, have you been pregnant or are you now pregnant?

Have you ever had cancer, including leukema? *

Have you ever received an organ, bone marrow or stem cell transplant? *

Have you ever had a stroke, heart attack, heart-related chest pains, heart disease or heart surgery? *

Have you ever had a bleeding problem, such as hemophilia or other clotting factor deficiency, or have you received human-derived clotting factor concentrates? *

Do you have HIV or AIDS or have you ever tested positive for the HIV virus, including screening tests? *

Have you ever tested positive for hepatitis, including screening tests, or have you ever had yellow jaundice, liver disease or hepatitis since the age of 11 years? *

In the past 3 years, have you had malaria? *

In the past 4 weeks, have you had any vaccinations (other than smallpox) or any kind of shot? *

Is there any other past or present health information that you think we should be aware of? *

(for example: past surgeries or serious medical conditions such as diabetes, fibromyalgia, blood clots, or an autoimmune disorder such as multiple sclerosis, iritis, episcleritis, or lupus)
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