Convalescent plasma

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Have you donated blood in England? *
Are you pregnant, or have had a baby in the last 9 months? *
Have you got, or have you had, any heart conditions? *
Have you had a blood, platelet or plasma transfusion since 1 January 1980? *

If you have had a plasma transfusion as part of treatment for COVID-19, please call us on 0300 123 23 23

Have you ever had cancer, apart from Basal Cell Carcinoma or carcinoma in situ? *
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Gender *
What is your date of birth? *
Ethnic group

Contact details

What best describes your circumstances in relation to COVID-19? *

Did you have any of the following symptoms?

(Please tell us yes or no to the following symptoms)

Fatigue *
Headache *
Loss of smell *
Sore throat *
Persistent cough *
High fever *
COVID-19 recovery date *

This is the first date when you no longer had any symptoms.

Statement of consent

By sending this form you agree that:

  • you have read the NHS Blood and Transplant privacy policy

  • you understand how your information will be used for the Convalescent Plasma Programme

Give consent *
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