Donor Form

Fill in the form below to see if you qualify as an Aevitas Sperm Donor.

    Surname

    First Names

    ID number

    Date of birth

    Age

    Race

    Ethnic ancestry (Please be specific)

    E-mail

    Cell

    Which venue would suit for the analysis?
    PinelandsStellenbosch

    How did you hear about us?
    GoogleMagazine/NewspaperFacebookFliersReferralOtherLinkedInInstagram

    Please specify:
    Referrer Name:
    Referrer Last Name:
    Referrer Cell / Email:

    Marital status

    Children

    Have you donated elsewhere previously?
    YesNo

    Highest qualification(s)

    Occupation (Please specify course and year if still a student)

    PHYSICAL APPEARANCE

    Eye colour

    Complexion
    LightMediumDark

    Hair colour

    Hair texture
    StraightWavyCurly

    Blood group

    Height (M)

    Weight (Kg)

    Which celebrities do you think you look like or have been told you look similar to

    PERSONAL HISTORY

    Health status

    Have you had a blood transfusion in the last 5 years?
    YesNo

    Are you currently on any medication?
    YesNo

    Please specify:

    Do you currently smoke?
    YesNo

    Please specify:

    Did you smoke previously?
    YesNo

    Please specify:

    Sexual Relationships

    Have you been treated for sexually transmitted diseases?
    YesNo

    Please specify:

    FAMILY MEDICAL HISTORY

    Do you have knowledge of any family related diseases?
    YesNo

    Please specify:
    For example: Heart disease, depression, genetically transmitted diseases (ie. Tay-Sachs, Porphyria, Alzheimers, Cystic fibrosis), Diabetes, Psychiatric disorders, other

    INTERESTS AND HOBBIES

    Interests and hobbies

    Any special skills, talents or abilities

    I (name) (date of birth) have been given information concerning sperm donor banking with ‘Aevitas Sperm Bank’ and understand all the points covered below. I have been given the opportunity to ask any questions and am satisfied with the answers given.

    The sperm collected for freezing at ‘Aevitas Sperm Bank’ will be used at fertility clinics for conception of babies. It is for clinical purposes, not research.
    I Accept

    An initial analysis will be done to ascertain the semen profile. (Costs for the analysis will be covered by the donor bank). Only donors with extremely good semen samples will be accepted. The analysis result will be given telephonically within two days after the sample is given.
    I Accept

    Once accepted, a donor will be expected to donate twice a week with three days of abstinence between samples (eg. Monday & Thursday OR Tuesday & Friday). The times and days for donating are as such: Vincent Pallotti 07:00-13:00; Stellenbosch (by appointment only).
    I Accept

    A blood sample will be needed at the third actual donation sample. A second blood sample will need to be given ONE MONTH AFTER completion of the donor cycle. (Costs for the blood tests will be covered by the donor bank). Donors will need to go to Vincent Pallotti Hospital. Blood samples collected will be used to identify any blood-related diseases (i.e. HIV, Hepatitis).
    I Accept

    We will freeze 90 straws of semen in total. (An average semen sample will have enough volume to fill 8 straws). The time it takes for a donor to complete the donor cycle will depend on the volume of semen a donor gives and the regularity of his visits to the clinic. If the three days of abstinence between samples is observed the semen volume and sperm count will be high and more straws will be frozen. This, combined with regular visits to the clinic, will result in the donor finishing the cycle sooner.
    I Accept

    A set amount of money will be given to the donor no matter what period it takes to complete the donor cycle. This will be paid as a lump sum after the second blood test results are available.
    I Accept

    The following need to be submitted before the last donation:

    • Completed extended questionnaire (will be supplied)
    • Baby/toddler photos, at least 3-5 (will be shown to patients)
    • Adult photos (will be kept confidential)
    • A copy of a certificate of highest education (at least matric)
    • A handwritten note and a voice note
    • Online personality assessment
    I Accept

    I agree (Donor) Date

    Aevitas Sperm Bank