Thank you for undertaking the Donor Mother Registration Process.
Please answer all applicable questions truthfully and to the best of your ability.
If NO, proceed to PART B. If YES, please answer the following questions.
If NO, proceed to PART D. If YES, please answer the following questions.
OPTION 1: For mothers who are currently breastfeeding
OPTION 2: For expecting mothers who wish to breastfeed their own child and also contribute, if possible, to the Mothers’ Milk Bank.
Please note: If you have chosen OPTION 2 and are successful in your Donor Mother Registration, a Mothers’ Milk Bank consultant will contact you one month after your baby’s birth to see how you are progressing and whether you still wish to donate to the Mothers’ Milk Bank. At this time, you may also have stored breastmilk available that you would like to contribute as a one-off donation. When indicating your intent to donate and submitting this registration, the will be no obligation for you to contribute to the Mothers’ Milk Bank if you are unable or unwilling to do so at that time.
I would require a breast pump
I have my own/I have access to a breast pump
(ie. illness, disease, having lived in the United Kingdom between the years 1982-1995)
(ie. smoker, drug user, consume large quantities of cafﬁnated/stimulant beverages, recent blood transfusion)
hereby certify that, to the best of my knowledge, all of
the information I have provided is correct and I have answered all questions truthfully.
The following section is optional, but we would really appreciate your assistance and consideration in taking the time to answer these additional questions.
You will be emailed a copy of this form.