Brighton Fertility Associates donor initial enquiry form

To become a donor at BFA you need to fill out the application form below. Your details will be discussed with you at a later consultation.

Please ensure you complete all sections of the form.

PERSONAL INFORMATION:

Forename(s)

Surname

Date of birth

Please indicate how you would like us to contact you.
(Note: Confidentiality is important to us. We will not leave messages unless agreed with you by indicating below.)
EmailPhoneText Message

Email

Telephone

ADDRESS:

Address 1

Address 2

Town

Postcode

Occupation

PHYSICAL CHARACTERISTICS:

Eye color

Hair color

Skin color (e.g: fair, tans easily, freckles, light brown, dark brown, etc.)

Height

Weight

PERSONAL INFORMATION:

Ethnicity

Nationality

Are you adopted?
YesNo

Have you ever donated at another centre in the UK or abroad OR by private arrangement (e.g over the internet, for a friend)?
YesNo

Have you ever made anyone pregnant?
YesNo

Do you suffer from any neurological disorders (e.g. epilepsy, unexplained fits etc.)?
YesNo

If yes, please provide details

Do you suffer from any heart conditions (e.g. arrhythmias, CVD)?
YesNo

If yes, please provide details

Do you suffer from any respiratory conditions (e.g. asthma, chronic bronchitis, Cystic fibrosis)?
YesNo

If yes, please provide details

Do you suffer from any blood conditions (e.g. Thalassemia, Sickle cell)?
YesNo

If yes, please provide details

Do you suffer from any skeletal problems/conditions affecting the bones (e.g. scoliosis, osteoporosis)?
YesNo

If yes, please provide details

To the best of your knowledge do you have any genetic conditions?
YesNo

If yes, please provide details

Is there any history of serious illness in your immediate family (mental, physical, genetic or medical)?
YesNo

Are you willing to be tested for HIV, Hepatitis and other infections on a regular basis?
YesNo

Have you ever been convicted of a criminal offence?
YesNo

How long do you intend to stay in the Brighton area?

Where did you hear about us?

What are your reasons for wanting to donate?

I have read and accept the privacy statement. Your information will be used for donor selection ONLY. If you are not suitable for donation your details will be destroyed, only your name and the date of application will be kept on record.

What happens next: Thank you for completing the sperm donor enquiry form. The BFA team will review your enquiry form and get back to you as soon as we can. If your answers are seen to be suitable we will invite you to book in for an appointment.