| * First Name: |
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| * Surname: |
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| * Occupation: |
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| * Date of Birth |
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| * Contact Email address: |
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| nb. Only valid email addresses will result in registrations |
| * Address: |
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| * Postcode: |
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| * Do You Smoke? |
No
Yes |
| * If so how many per day? |
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| * Do you drink alcohol? |
No
Yes |
| * If so how, many units per week? |
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| * Contact Phone Number |
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| * Contact Mobile Number |
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| * Sexual Preference |
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| * Marital Status |
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| * Ethnic Origin |
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| * Country of birth |
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| * Hair Colour |
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| * Eye Colour |
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| Please check your answers to weight and height – incorrect responses here will vastly reduce your selection chances. |
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* Height |
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| * Weight |
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* Any history of multiple births?
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No
Yes |
| Identical? |
No
Yes |
| * Are you one of a multiple birth? |
No
Yes |
| * Blood Group |
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| Have you or any member of your family, ever been dignosed with any of the following conditions? |
| * Cancer |
No
Yes |
| * Diabetes |
No
Yes |
| * Heart Disease |
No
Yes |
| * Alcoholism |
No
Yes |
| * Arthritis including gout rheumatoid |
No
Yes |
| * Asthma |
No
Yes |
| * Autism |
No
Yes |
| * Auto-immune disease |
No
Yes |
| * Congenital hip disease |
No
Yes |
| * Cystic fibrosis |
No
Yes |
| * Deafness |
No
Yes |
| If answered yes then please elaborate |
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| * Down Syndrome |
No
Yes |
| * Epilepsy |
No
Yes |
| * Dyslexia |
No
Yes |
| * Blindness and cataracts |
No
Yes |
| * Kidney Disorders |
No
Yes |
| Malformations, including |
| Have you or any member of your family, ever been dignosed with any of the following conditions? |
| * Cleft Palate |
No
Yes |
| * Dwarfism |
No
Yes |
| * Club foot |
No
Yes |
| Mental Illness, including |
| Have you or any member of your family, ever been dignosed with any of the following conditions? |
| * Depression |
No
Yes |
| * Schizophrenia |
No
Yes |
| * Manic depressive psychosis: |
No
Yes |
| * Retardation |
No
Yes |
| * Sickle cell anaemia |
No
Yes |
| * Thyroid disorder |
No
Yes |
| * Any personal history of STD's |
No
Yes |
| If so, please give details... |
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If you have answered yes to any of the above medical questions
please enter any details here |
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* Have you ever fathered children?
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No
Yes |
| If so, how many |
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| If so, what age/s |
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| If so, what sex/es |
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| Any child conceived from your donations may request details of the donor when he/she becomes 18 years of age. |
| Is this acceptable? |
No
Yes |
| Extra Information |
| * Brief note as to why you want to register as a donor |
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| * Brief history of yourself and family history |
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| * Brief history of your education, achievments & qualifications. |
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| * What are your hobbies and interests
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| What is your religion |
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| * Would you allow Fertility1st to give your details to women who wish direct contact with a donor to arrange their own fresh sperm donations. You would need to negotiate expenses with the recipient. |
| If you choose yes to this option we will call you to discuss this further. |
No
Yes |
* Would you consider being a frozen sperm donor with the understanding that the child has the right to find your details when they become 18 years of age.
You are in no way financially responsible for any children born resulting from frozen sperm donation. |
| If you choose yes to this option we will call you to discuss this further. |
No
Yes |
| I confirm that I have read and understood the terms and conditions for Fertility 1st products and services and agree to be bound by them. I acknowledge that I am over 18 years of age, and that the answers to my questions within this questionnaire are to the best of my knowledge true and accurate. Further I understand that Fertility 1st Limited will retain my details on file for the purposes of providing certain information to appropriate recipients, will not be held responsible for any actions as a result of the dissemination of my information and finally that I have the control to amend or remove my details at any time. |
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Please tick to confirm you have read and understood our terms and conditions |
| * = Required field. |
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