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.


ID number

Work telephone



Address 1

Address 2


Postal code




Baby's name

Baby's date of birth


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

Do you regularly have more than 50ml of hard liquor 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?


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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