Other Disorders

Other Disorders

Questions?

If you have any questions, please check our FAQs.
If you would prefer to speak with an Access Biologicals Donor Representative, please call us at: 800.510.4003 option #2.

Complete the pre-screening form below to find out if you qualify. A representative will contact you with more information shortly.
1.
Are you currently being seen by a doctor or clinic for this condition?

YesNo. I am no longer seeing a doctor.No. I did not see a doctor.

2.
When did you first visit the doctor for this condition?
3.
Do you currently have any symptoms for this condition?

YesNo. I had symptoms at first but they are mostly gone nowNo. I never had any symptoms

4.
If you no longer have symptoms, how long ago did they go away?
5.
Did the doctor prescribe any medications to you for this condition?

Yes I am still taking the medicationYes. But I am NO longer taking the medicationsNo. The doctor did not give me any medication

6.
Can you provide copies of any recent results or lab work related to your diagnosis?
(if Yes, you can email, fax to 760.931.8456, or upload)info@accessclinical.com

YesNo

7.
What symptoms are you currently experiencing ?
(Please include the approximate date of onset of each symptom)
8.
Have you ever been diagnosed with:
(check all that apply)

SyphilisHIV/AIDSHepatitis CHTLV

9.
Contact Information (All fields are required)
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