| Your Title |
|
| * Your First Name |
|
| * Your Surname |
|
| * Your Maiden Name |
|
| Partners Title |
|
| Partners First Name |
|
| Partners Surname |
|
| * Contact Email address |
|
| nb. Only valid email addresses will result in registrations |
| * Your Address |
|
| * Your Postcode |
|
| * Phone Number |
|
| * Mobile Phone Number |
|
| * Ethnic Origin |
|
| Occupation |
|
| Partner's Occupation |
|
| * Date of Birth |
|
| Partner's Age |
|
| Number of Children Planned for |
|
| Sexual Preference |
|
| * Marital Status |
|
| * Have you had any previous conceptions / attempts |
No
Yes |
| If so, were they artifically inseminated? |
No
Yes |
|
* Do you have any known problems conceiving? |
|
| * Brief note as to your history and why you want to do this |
|
| * Is there any reason that you know of that you may be deemed as an unfit parent? |
|
| Have you or any of your immediate family ever been diagnosed with any of the following conditions? |
| * Depression: |
No
Yes |
| * Schizophrenia: |
No
Yes |
| * Manic depressive psychosis: |
No
Yes |
| * Down Syndrome: |
No
Yes |
| * Have you ever recieved treatments for addiction, ie: alcoholism, drug abuse etc...? |
| Please select: |
No
Yes |
| If answered yes then please give details |
|
| * Are there any medical or psychological conditions we should know about which may affect conception, pregnancy or the parenting of a child? |
|
| *Type of Insemination required |
|
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 Fertility1st.com 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.
|
|
|
Please tick to confirm you have read and agree to our terms and conditions |
We want to meet a donor
Congratulations, once you click "Submit this form to our staff for appraisal" your details will be recorded and to complete your application you will now need to pay for your registration. Your credit/debit card will be debited the registration fee of £39.00 on the next screen. |
Other methods of payment:
If you wish to pay by cheque, please send to:
Accounts:
Fertility 1st Ltd
Accounts Dept
26 St Johns Road
Reading
Berks
RG1 4EB
Cheques should be made payable to Fertility 1st Ltd
Email:info@fertility1st.com |
| * = Required field. |
|
|
