Hemeos Donor Application

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Contact Information


 

Address Information


 

Personal Information


    Please Select All That Apply     

Prior to today, have you ever done a cheek swab to register as a donor?

 

A Family Member or Friend Who Can Reach You


Please provide contact information for a family member or friend who will know how to reach you in case we cannot contact you using the information you provided.

 

 

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Health Information

Hemeos needs potential donor health information to determine if they are suitable donors. Answering yes to a question does not necessarily eliminate you from being a donor, but may require more follow up if selected as a donor.


Have you ever been diagnosed or treated for any of the following conditions?

1. Stroke?

2. Have you ever had cancer?

3. Prescription pain medication?

4. Anxiety or depression?

5. Autism or Asperger’s syndrome?

6. ADHD or ADD?

7. High Cholestrol?

8. Any heart disease?

9. Arthritis?

10. Chronic Fatigue Syndrome?

11. Seizures?

12. Kidney Stones?

13. Asthma?

14. Diabetes?

15. An Aneurysm?

16. Any Blood Clotting Disorder?

17. Hemophilia?

18.Anemia?

19. Allergies?

20. Have you ever had any autoimmune disease?

21. Have you ever had a concussion?

22. Long term infections disease such as Hepatitis, Herpes, HIV, etc?

23. Chemotherapy or radiation therapy?(Radioactive Iodine treatment for thyroid cancer is acceptable. Localized bead radiation for prostate or breast cancer is acceptable)

24. Chronic, on-going, significant pain to areas of the spine, back, or neck that interferes with you daily activities AND requires regular chiropractic treatments or regular physical therapy?

25. Have you smoked at least 100 cigarettes in your lifetime?

26. Has anyone in your immediate family (parents, siblings, or grandparents) been diagnosed with Alzheimer’s?

27. Please list any diagnosis or treatment for any conditions not mentioned above, if any.

28. Please list any prescription medications you've taken for anything mentioned on this form.

 

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Donor Information and Consent Form


I have read and understand the Donor Registration and Consent to register with Hemeos and agree to its term.

 

Research Consent Form


I have read an understand the Research Consent Release and agree to its terms.

 

Terms of Use and Privacy Policy


I have read the Terms of Use and the Privacy Policy for my application to join the registry, which includes providing accurate information on the online registration form.  

 

Electronic Signature


By entering my full name (First Middle Last) into the field below, I acknowledge that I have read, understand and agree with the above. I understand that my typewritten name in this field constitutes my electronic signature.