Fertility Associates - Becoming A Sperm Donor

First Name*

Last Name*

Date of Birth*

Email*

Phone
Enter in format 09-1234567

How do you prefer to be contacted?*

Type of Donor*
A personal donor is when you are donating to a specific person.

If Clinic, which age band are you in?*
Please note: Sperm donors must be aged between 20 - 45 years.

If Clinic, Are you a NZ Resident

If Personal, what is your recipients name - the person you are donating to *

If Personal, do you know your recipients file number?*

City - Closest clinic*
You must be able to travel to this location

What is your ethnicity

Do you have a partner and are they aware of your intention to donate?

Do you have any children of your own?

If Yes, how many?

Have you ever donated sperm before?

If Yes, how many children resulted from your donation? If known

Do you have any serious health conditions?*

If Yes, please provide more information

Are you on prescribed medications?*

If Yes, please provide more information

Where did you hear about becoming a sperm donor

If Other, please provide more information

Comments welcome