• Sperm Donor Questionnaire

  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Where did you hear about us?*

  • Please supply the following information in order for us to complete your application and ensure that it complies with the legal requirements for donation.

    We understand that some of the questions are very personal, but rest assured that your answers will be kept private.

  • Rows
  • Do you or someone in your immediate family (parents, grandparents, siblings, children) have a major mental or physical illness or medical condition? (e.g. diabetes, epilepsy, cancer)*
  • Have you traveled abroad in the recent 12 months?*
  • Are you currently receiving any treatment?*
  • Do you have any sexually transmitted illnesses, or have you ever had any?*
  • Do you use any illicit substances?*
  • Have you ever been arrested or charged with a crime?*
  • Have you provided sperm or applied to donate sperm to another HFEA-approved sperm bank?*
  • Have you ever contributed or applied to donate your sperm in any other setting inside the country or abroad (e.g. via the internet, to a friend)?*
  • Rows
  • 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.

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