The Milk Bank at Chester

Full Name*

Address*

Email address*

Phone Number*

Donor's Date of Birth

Baby's Name, Date of Birth and Gestation*

What has made you think about donating your milk?

Do you have frozen milk to donate or are you thinking about expressing in the future?

If you have frozen milk to donate, where is it stored?

Does any member of your household smoke?*

Yes
No

Do you use nicotine replacement therapy including inhalators, patches or gum?*

Yes
No

Do you regularly exceed 1-2 units of alcohol once or twice a week?*

Yes
No

How many caffeinated drinks do you have each day? Eg 1 x coffee and 1 x tea

Are you taking or have you recently taken any medication or herbal supplements including but not limited to: antibiotics, painkillers (ie: ibuprofen), anticoagulant injections, herbal remedies or vitamin supplements?*

Yes
No

Have you had a blood transfusion, blood products or any piercings, tattoos or acupuncture in the last 4 months? You may still be able to donate however you may have to delay your blood test.*

Yes
No

Have you ever been told you have an increased risk of CJD (mad cow disease)?*

Yes
No

Have you had any immunisations in the last 6 months (other than flu or whooping cough)?*

Yes
No

Have you recently been exposed to or previously tested positive for any of the following: HIV 1/2, hepatitis B/C, HTLV 1/2, syphillis, herpes or other infections?*

Yes
No

If you have answered yes to any of the questions above please give details below.

Are you using any products containing retinol or its derivatives? (Retinyl Acetate, Retinyl Linoleate, Retinyl Palmitate, Retinyl Proprionate). NB retinol is commonly found in anti-ageing / lifting toners and face creams.

Yes
No

How did you hear about the milk bank? Please tick all that apply.*

Baby had donor milk
Social Media - Facebook, Instagram, Twitter
Friend had donated
Neonatal Unit
Health Visitor / Midwife / Infant Feeding Team
Flyer / leaflet / poster
Antenatal Group
Breastfeeding Group

Thank you for enquiring about donating milk, we will respond to your enquiry within 7 days.

Name

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Telephone Number 01244 362226 or [email protected]

Become a Donor

We have provided milk to over 70 hospitals since 2014

For Help and Advice

Telephone Number 01244 362226 or [email protected]

Become a Donor

We have provided milk to over 70 hospitals since 2014

For Help and Advice

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