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01244 511440
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01244 511441
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Become a Donor
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?
I have frozen milk stored I would like to donate
I am thinking about expressing in the future
I have milk already frozen and I am 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 including antibiotics, painkillers or anticoagulant injections following birth?
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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.
How did you hear about the milk bank? Please tick all that apply.
*
Health Visitor / Midwife / Infant Feeding Team
Neonatal Unit
Friend
Flyer / leaflet / poster
Google / other search engine
Facebook
Internet forum eg Mumsnet / Babycentre
Thank you for enquiring about donating milk, we will respond to your enquiry within 7 days.
Email
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