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During standard donor infectious disease testing following blood collection, donors who test positive by screening and confirmatory test(s) for syphilis are indefinitely deferred from blood donation. To assess a donor's eligibility for future blood donations, a healthcare provider is required to submit subsequent medical evaluation information, including but not limited to, any known history of syphilis, any diagnostics testing performed (if deemed necessary), and/or treatment of syphilis.
Click on button below to view Physician Evaluation Syphilis Form. Please email the completed form to 3-DonorAdvocate@impactlife.org or to submit digitally, click the button below and complete the entire PDF form. If submitting digitally, a copy of the completed form will be emailed to you as a receipt.
Click here for Physician Evaluation for Syphilis