Becoming a sperm donor

Fields marked * must be completed.

Your Contact Details
*Your full name: 
*Date of birth and age:  /   /    *Age: 
*Your address and postcode:
Telephone Number: *
*Email Address:
Is it OK to contact you using this email address? 
*Choose your closest CARE clinic:
How did you hear about us?

If other, please specify
Personal Questions
Due to the guidelines surrounding sperm donation, we must ask the following very sensitive questions.
*Are you adopted?
*Have you ever had sexual contact with a prostitute?
*Have you ever taken drugs intravenously?
*Have you ever been screened or treated for sexually transmitted diseases (STD´s)?
*Have you ever had a sexual partner whom you consider could have answered yes to any of the above questions?
*Have you been a sperm donor anywhere else?
*Are your family fit and healthy?
*Have there been any deformities in your family (e.g. Spina Bifida, Cleft Palette)?
*Do you or any of your family suffer from Diabetes, Asthma, Hepatitis, Epilepsy/Mental Disorders, Haemophilia, Heart Condition/High Blood Pressure, Genetic Disorders or Thyroid Problems?
Thank you for taking the time to complete this questionnaire