Donor Testing Request Form

Your submission has been confirmed. Please print off your completed order form and send with your blood samples to:

Donor Testing Laboratory
Memorial Blood Centers
737 Pelham Blvd.
St. Paul, MN 55114
Your submission has been confirmed. Please print off your completed order form and send with your blood samples to:

Donor Testing Laboratory
Memorial Blood Centers
737 Pelham Blvd.
St. Paul, MN 55114
Your submission has been confirmed. Please print off your completed order form and send with your blood samples to:

Donor Testing Laboratory
Memorial Blood Centers
737 Pelham Blvd.
St. Paul, MN 55114
* = Required Fields
Please select test(s) needed below (check all that apply). Assays marked with ^ are not approved for patient diagnostics.
IDM Panels: HBsAg, MPX 2.0 NAT, Anti-HIV-1/2+O, Syphilis MHA, Anti-HTLV I/II, Anti-HBc, Anti-HCV, ABO/Rh, CMV Total. NOTE: CMV Total does not reflex. If CMV reflex testing is needed, indicate below.
Female HCT/P Panels: HBsAg, MPX 2.0 NAT, Anti-HIV-1/2+O, Syphilis MHA, Anti-HBc, Anti-HCV, Chlamydia, Gonorrhea.
Male HCT/P Panels: HBsAg, MPX 2.0 NAT, Anti-HIV-1/2+O, Syphilis MHA, Anti-HTLV I/II, Anti-HBc, Anti-HCV, CMV Total, Chlamydia, Gonorrhea.
























Urine: Must be filled between black lines.
Swab: Send blue swab

Please print your completed form and include with your tubes.