RECIPIENT

Registration Form
 

For Pasteurised Donor Human Milk Feeds

Thank you for undertaking the Recipient Registration Process.
Please answer all applicable questions truthfully and to the best of your ability.

PART A

PART B

PART C

How many bottles of breast milk do you wish to receive?

PART D

Please give details (ie. illness, premature birth, no or little milk supply, surrogacy, adoption, alleriges, other).

PART E

I,

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.

I give consent for my baby to receive Pasteurised Donor Human Milk (PDHM). I understand that due to its limited supply pasteurised donor human milk can only be supplied to my baby when available.

Signature *

Please sign the form

PART F

The following section is optional, but we would really appreciate your assistance and consideration in taking the time to answer these additional questions.

Thank you!

You will be emailed a copy of this form.