Donors

Thank you for wanting to become a breastmilk donor. Ideal candidates are in good health and have access to a fridge and freezer. There is no financial compensation but by filling out this form you are on your way to helping an infant in need. We canít thank you enough.
Name


Surname


ID number


Cell


Alternative telephone number


E-mail


Address 1


Address 2


Suburb


Postal code


City


Province


Country


Baby's name


Baby's date of birth


Questionnaire

Have you received a blood transfusion or blood products in the last 12 months?
Yes   No  

Do you regularly have more than 50ml of alcohol or its equivalent in a 24-hour period?
Yes   No  

Are you a vegetarian?
Yes   No  

If yes, do you supplement your diet with B12 vitamins?
Yes   No  

Do you smoke?
Yes   No  

Regular use of medications or use of radio-active drugs or cytotoxins?
Yes   No  

Do you use habit-forming drugs?
Yes   No  

Have you ever had hepatitis B, HIV or TB?
Yes   No  

Have you ever had a sexual partner who is at risk for HIV, takes habit-forming drugs or is a hemophiliac?
Yes   No  

Do you have a copy of the results of your anti-natal HIV tests?
Yes   No  

If not, would you be prepared to undergo a rapid test for HIV at your expense and submit the results to the screening officer?
Yes   No  

Do you own a breast pump?
Yes   No  

Unfortunately, we are not able to supply breast pumps, thus, unless you are able to hand express, owning a breast pump is essential.

If not, how will you be expressing to donate?


Do you have access to a freezer as we are only able to collect frozen milk?
Yes   No  

Do you use any prescribed medication?
Yes   No  

If yes, please specify what prescribed medication you use


Do you use any over the counter medication?
Yes   No  

If yes, please specify what over the counter medication you use


Do you use any herbal, homeopathic medication or remedies?
Yes   No  

If yes, please specify what herbal, homeopathic medication or remedies you use


Do you use any galactogogues / substances to increase breastmilk supply?
Yes   No  

If yes, please specify what galactogogues / substances you use to increase breastmilk supply


Will you be a once off donor or a long term donor?
Once off donor   Long term donor  

If you are a once off donor, when was the milk you are donating expressed?


How did you hear about us?


Subject


Can we send you communication regarding South African Breastmilk Reserve
Yes    No

Please send communication via SMS/E-mail (Choose one or both)
SMS    E-mail






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