Healthcare Donor Availability Form

Healthcare Donor Availability Form

This form collects donor identification, medical screening information, and specific availability to facilitate donation scheduling and suitability assessment. Completion authorizes release and use of relevant protected health information solely for coordination of donation services. Submission does not guarantee acceptance or appointment confirmation.

Patient / Donor Information

Emergency Contact

Insurance / Billing (if applicable)

Donation Type & Availability

Types of donation willing to consider (check all that apply):

Whole Blood    Platelets    Plasma    Double Red Cells    Bone Marrow    Stem Cell    Tissue    Organ (specify in notes)

Available from:    Available to:

Preferred days (check all that apply):

Mon   Tue   Wed   Thu   Fri   Sat   Sun

Preferred time of day:

Morning (8am–12pm)   Afternoon (12pm–4pm)   Evening (4pm–8pm)

Willing to travel to alternate locations: Yes    No

Available for on-call / short-notice donation: Yes

Preferred contact method (check all that apply):

Phone   Email   SMS / Text Message

Medical History / Screening

By checking the box below, I attest that the information provided on this form is complete and accurate to the best of my knowledge. I will notify the organization promptly of any changes to my health status or contact information prior to any scheduled donation appointment.

I certify that the above statements are true and complete.

Privacy Authorization & Release

I authorize release and use of my health information to the extent necessary to evaluate suitability and to schedule, coordinate, and carry out donation services. This authorization is limited to information reasonably necessary for scheduling and medical screening and may include contact with other clinical facilities and laboratories for verification.

This authorization expires on:

I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by law.

I acknowledge and authorize use/disclosure of my information as described above.

Attestation and Consent

I attest that I am at least 18 years of age (or have legal authority to consent), that I understand the screening requirements for donation, and that I have answered all medical questions truthfully. I consent to be contacted to arrange donation appointments and understand that final medical suitability may be determined at the time of donation by a qualified clinician.

I attest and consent as stated above.

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