Sperm Donor Questionnaire

Sperm Donor Questionnaire
Name*
First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*
MonthDayYear
Date
Country of Birth
Ethnicity*
Where did you hear about us?*
Social MediaFriends/ FamilyMedical Center(s)News/ MediaOther
Please verify that you are human*

	YES/ NO
Are you an adopted child?
Are you donor-conceived?
Do you know who your biological parents are?
Do you consider yourself to be in good physical condition?
Do you participate in anal sex now or in the past?
Do you take a cigarette?
Have you ever gotten a woman pregnant?
Do you have any children of your own?
Is it possible for you to show photo identification (passport or driver's license)?

	Information
Ethnicity of your biological mother
Ethnicity of your biological father
Biological maternal grandmother's ethnicity
Biological maternal grandfather's ethnicity
Biological paternal grandmother's ethnicity
Biological paternal grandfather's ethnicity

Could you please tell us your motivation to donate your sperm briefly.*
I certify that I have completed this form completely and truthfully to the best of my knowledge.*
Clear
What is going to happen next?
The donation coordinator will examine your completed questionnaire. We may contact you for additional information about your responses. If your responses indicate that you meet the requirements to become an egg donor/sharer, you will be invited to an initial appointment at the clinic. Please verify that you have provided us with your phone number and email address at the beginning of this form.
Should be Empty: