FertilityMate.com

Already registered? Click here to Login

Dear Potential Donor
Please consider the following before you continue with the application form:

1. Who will support you during the process (it should be someone with whom you have a very close relationship) eg boyfriend, parents, older sister etc
2. If you do have a partner - does he/she know about your plans to donate?
3. If you get involved with a new partner and they do not understand or agree with you donating, what are you going to do?
4. A gals BF is often her Mom - if you are going to disclose your intention's to her about joining FertilityMate.com as a donor - how does she feel?
5. Are you sure that the time commitment expected of you will not be a problem? There will be at least 7 visits to the clinic from start of process to end. These visits cannot be scheduled for after hours or Saturdays.
6. Have you read FertilityMate's FAQ's (Frequently asked questions) - if not, please go to http://www.fertilitymate.com as this will provide you with the information that you need to make an informed decision about becoming a FertilityMate Donor.

In which City do you currently live?

First Name

Last Name

Birth Date

-- Only ages between 20 and 33 permitted

Height in Meters

Weight in Kilograms

Is your period regular?

Where can you donate?

What method of birth control are you using?

Have you been a donor before?

Do you smoke?

Are you currently on any medications, herbs or supplements?

Are you HIV Positive?

Have you or any of your immediate family been formally diagnosed by a medical professional as suffering from any of these serious mental disorders: bipolar / schizophrenia / other serious mental disorders ?

Are there any known genetic diseases or conditions that run in your family? Please give their details below

Conditions	Family Member with Condition (Incl Grandparents)	Medication Prescribed	Age of Onset

Your Email Address

Would you like a second email address to be copied in on all correspondence?

Home Phone

Work Phone

Cell Phone

Choose a Registration Password (longer than 4 characters in length)

Confirm your chosen Password

How did you hear about FertilityMate?

Extra details on how you heard about FertilityMate:

If you found out about us on a leaflet, business card or banner, please tell us where specifically you found them...