Anaheim Ducks Appointment Request Form

There is currently an urgent need for blood. Thank you for your interest in donating! UCI Health and the Anaheim Ducks are partnering for a blood drive on Thursday, December 8, 2022. Everyone who donates will receive a Troy Terry bobble head, choice of gift card to Target, In N Out or Starbucks, and entry into a drawing for an autographed Anaheim Ducks jersey, all courtesy of UCI Health.  

Due to COVID-19, extra precautions will be taken for your safety as well as the safety of our staff.  All donors are required to wear masks. Please note that for safety reasons, we are unable to allow children on the bloodmobile. Therefore do not bring children that require supervision outside of the bloodmobile. The bloodmobile will be parked at the front entrance. From Katella, turn on South Douglas, the bloodmobile will be in the first lot on the right side. Please read the important COVID-19 information below and do not make an appointment if any apply to you.  In addition, we recommend reading the basic donation requirements prior to making your appointment. You can find them here: http://www.ucihealth.org/medical-services/blood-donations

IMPORTANT COVID-19 INFORMATION:

Please note that if you have had any of the following symptoms in the last 14 days you will not be able to donate:  Fever, chills, muscle aches, cough, shortness of breath, unexpected fatigue, sore throat, loss of taste or smell, headache, diarrhea, vomiting or nausea. Please read the following deferrals related to COVID-19 before making an appointment.                                  

  1. Am I deferred for COVID-19 testing for suspected COVID symptoms – You must be symptom free for at least 14 days before the donation, even if test was negative. 
  2. Am I deferred for COVID-19 testing for living with someone with COVID? YES- You must be symptom free for at least 14 days before donating.                                           
  3. Am I deferred for a Confirmed positive COVID-19 test result –YES- You must wait 14 days after complete resolution of symptoms  
  4. Am I deferred if I received a COVID-19 vaccine? NO- As long as it was the Pfizer, Moderna or Johnson & Johnson vaccines which have received emergency approval from the FDA, there is no deferral. If you are a part of a study for a vaccine from another manufacturer that has not received FDA EUA approval, the deferral is one year.                                                                         

Please complete and submit this online donor form. Appointments are currently available for the time selections shown. Thank you for volunteering to donate and we look forward to seeing you at Honda Center.

Fields with * are required.
 
*
 
 
YOUR INFORMATION
 
Legal First Name:*
 
Legal Middle Name / Initial:
 
Legal Last Name:*
 
What do you prefer to be called?
 
Date of Birth:*
Format: (mm/dd/yyyy) and must be 17 at time of donation. Minor Consent Form (if under 18)
 
Gender:*
 
Email:*
 
Confirm Email:*
 
Preferred Phone:*
 
Phone:*
 
APPOINTMENT INFORMATION
 
I have had one or more of the following symptoms in the last 14 days: fever, chills, muscle aches, cough, shortness of breath, unexpected fatigue, sore throat, loss of taste or smell, headache, diarrhea, vomiting or nausea
 
I have been exposed to someone who tested positive for COVID-19 or is suspected to have COVID-19 in the past 14 days.
 
Blood Type:
 
Appointment Date:*
 
Appointment Time:*
You must first enter an appointment date to select a time.