Sperm Donors Inc.
P.O. Box 533 Meridian ID 83680-0533 (208) 921.1438 fax (208) 895-8072
www.SpermDonorsInc.com
Dear Prospective Donor,
Thank you for your interest in our sperm donation agency.
Please find attached the application to become a Sperm Donor that you are requesting.
SDI is an anonymous donation services (unless both parties unanimously agree to meet
one another). The compensation that you will receive for being a Sperm Donor with our
agency ranges from $2,000+ and increase as you complete cycles. This payment is
disbursed to you within 72 hours after your donation is completed.
Please fill in all questions on the application to the best of your knowledge, using a black
ink pen. Please put some time and effort into the application, being as thorough as
possible. Fax it back to 208.895.8072.
Upon returning the application by fax or mail, please sign, date and return the “Web Site
Release Form”. Please also e-mail 5-6 current photos of just you to
Kevin_sdi@yahoo.com. Color, relatively close up, that shows your eye, hair color. These
need to be a resolution of at least 200 pixels/inch and 4X6 in size so that they can be
edited and cropped in Photoshop. Also 1-2 childhood pictures of yourself if you have
them.
If you have any questions please feel free to contact one of our staff members at
(208) 921.1438.
Sincerely,
Sperm Donors Inc.
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Sperm Donation Inc
www.SpermDonorsInc.com
Sperm Donor Health History and Background
PERSONAL INFORMATION:
Name: ______________________________ ID# (office use only)___________________
Mailing Address: ___________________City ______________State____________ Zip________
How did you hear about our agency?
____ Website ____ Friend ____ Other
If you checked other please list where you heard about us: _________________
Email Address: ___________________________________________________
Home Phone: __________________Work Phone: _________________________
Where can SDI leave messages? ___________________________________
HEALTH INSURANCE
Are you currently covered by a Health Insurance Plan? ____ yes ____ no
If yes, Name of Plan: ________________________________________________
Who is the Primary Insured? __________________________________________
From 1980 until 2006, have you ever lived in or travel to Europe? (includes England, Ireland,
Scotland, Wales and the Isle of Man, the Channel Islands, Gibraltar or the Falkland Islands)
If so, where? ____________________ How Long? _____________________
Current Occupation: ___
Since we use first names and an assigned ID number for our donors, do you mind if we use your
first name with our couples to identify you? ____ yes ____ no
If no, what would you like your “pseudo (fake) donor name” to be for us to identify
you.________________________________________
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** This page is only viewed by our office staff and is kept confidential
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You are not eligible to donate if you fall under any of the following criteria:
--Persons who spent 3 months or more cumulatively in the United Kingdom from 1980 through the
end of 1996.
--Persons who are current or former US Military members or civilian military or dependents of a
military member or civilian employee who resided at US military bases in Northern Europe
(Germany, Belgium and the Netherlands) for 6 months or more cumulatively from 1980 through
1990 or elsewhere in Europe (Greece, Turkey, Spain, Portugal and Italy) for 6 months or more
cumulatively from 1980 through 1996.
--Persons who spent 5 years or more cumulatively in Europe from 1980 until present (including
time spent in the UK from 1980 through 1996).
--Persons who received any transfusion of blood or blood components in the UK or France
between 1980 through present.
--Persons or their sexual partners who were born in certain countries in Africa (Cameroon, Central
African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria) after 1977. Or,
persons who have received a blood transfusion or any medical treatment that involved blood in
the countries listed in this paragraph.
Have you spent any time in any of the following countries from 1982 through current? If so, mark
the country with an X and give the time period that you have spent total.
Example
Albania X Jan-Feb 1986 (5 weeks)
Mark if you have Length of Stay
Been to this Country Since 1982
Albania _ _______________________________
Austria _ _______________________________
Belgium _ _______________________________
Bosnia-Herzegovina _ _______________________________
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Bulgaria _ _______________________________
Croatia _ _______________________________
Czech Republic _ _______________________________
Denmark _ _______________________________
Finland _ _______________________________
France _ _______________________________
Germany _ _______________________________
Greece _ _______________________________
Hungary _ _______________________________
Ireland _ _______________________________
Italy _ _______________________________
Liechtenstein _ _______________________________
Luxembourg _ _______________________________
Macedonia _ _______________________________
Netherlands _ _______________________________
Norway _ _______________________________
Poland _ _______________________________
Portugal _ _______________________________
Romania _ _______________________________
Slovak Republic _ _______________________________
Slovenia _ _______________________________
Spain _ _______________________________
Sweden _ _______________________________
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Switzerland _ _______________________________
United Kingdom _ _______________________________
See below for the countries that pertain to United Kingdom
United Kingdom includes the following: England, Northern Ireland, Scotland, Wales, the
Isle of Man, the Channel Islands, Gibraltar, and
the Falkland Islands.
Yugoslavia _ _______________________________
Within the last year have you been treated for any of the following and if your answer is
Yes list the date of infection.
Have you been diagnosed with West Nile Virus in the past year? __________
Have you been diagnosed with Syphilis in the past year? __________
Have you been diagnosed with Chlamydia in the past year? __________
Have you been diagnosed with Gonorrhea in the past year? __________
Have you had a tattoo or body piercing in the past year? __________
Have you had the smallpox vaccination within the past 8 weeks? _________
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Sperm Donor Health History and Background Information
DONOR ID#: _______________________[Assigned by SDI]
Name:_____________________________
Is there any time that you will be out of town in the next six months? __________
Have you lived outside the United States between the years of 1982 – 1996
for more that 3 months? ___yes If so where ___________________ ___ no
If the couple that selected to work with you wanted to meet you, would you be open to it? ____
yes _____ no
Would you be open to have a phone interview with the couple held anonymously through SDI’s
office if the couple chose to? ____ yes _____ no
Do you have a car? ____ yes ____ no
If no, do you have access to a car? ____ yes ____ no
Date Of Birth:________________ Age:________ Race:_________________
Height:______ Weight:______ Eye Color:___________ Hair Color:_________
Hair: (Check One) Complexion (Check One) Body Bone Structure (Check One)
___ straight ___ fair ___ small
___ wavy ___ medium ___ medium
___ curly ___ dark ___ large
Blood Type: _______________________
Ethnic Origin Ancestry (Italian, German etc.): Mother: ______________________
Father: _____________________
Religion Born Into: __________________________________________________
Sexual preference: _______ Heterosexual _________ Bi-Sexual ________ Homosexual
Have you ever been convicted of a felony? ____ yes ____ no
If yes, explain and list any arrests, convictions and sentences: ____________________
______________________________________________________________________
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MARITAL STATUS
____ Married ____ Single ____ Divorced ____ Separated ____ Widowed
If not married, are you currently involved in a committed relationship?
____ yes ____ no
Sexual preference: ______ Heterosexual ______ Bi-Sexual ______ Homosexual
EDUCATION
In high school or college were there specific areas that you excelled in or where you a part of any
after school programs?
________________________________________________________________
________________________________________________________________
________________________________________________________________
Are you currently enrolled in a college? ____ yes ____ no
If yes, what college are you attending and Major? __________________________________
If no, what college did you attend and Major? __________________________________
Please check the highest levels completed:
____ High School GPA:_____
____ Junior College GPA:_____
____ College GPA:_____
____ Advanced Degree in __________________________________ GPA:____
____ Other (Please Specify) _______________________________________________
SAT Scores (if know):_______________ ACT Scores (if know) ______________
Pease answer the following questions thoughtfully and completely so that the interested
couples can get to know you better as an individual.
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Why do you want to be an Sperm Donor?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Please describe your personality and character: ______________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
What are your talents, interest and hobbies? _________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
What characteristics do you think make you a unique individual? Please include any
accomplishments you have achieved?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________I
If you are married, or in a committed relationship, have you discussed donating with your husband
or partner? If so, what was their reaction?
_____________________________________________________________________________
_____________________________________________________________________________
Have you discussed donating with your family or friends? If so, what was their reaction?
_____________________________________________________________________________
_____________________________________________________________________________
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FAMILY BACKGROUND (Do not list hospital names, actual business names, etc. with the
exception of Schools)
Where were you born? ___________________________________________________
Where did you spend your childhood? _______________________________________
Father’s Occupation? _____________________________________________________
Father’s Highest Level of Education? ________________________________________
Name of School (if known)? _______________________________________________
Mother’s Occupation? ____________________________________________________
Mother’s Highest Level of Education? _______________________________________
Name of School (if known)? _______________________________________________
Parent’s Marital Status? __________________________________________________
If parents are separated how old were you when they separated? _________________
Parents State of Residence? ______________________________________________
FERTILITY HISTORY
Have you ever been told that you had a low sperm count: ____ yes ____ no
Have you ever been diagnosed as having erectile disfunction? ____ yes ____ no
How many children have you fathered, if any? __________________________________
For each child, please write date of birth, sex, and any special health problems:
Date of Birth Sex Special Health Problems
______________________________________________________________________
_____________________________________________________________________________
_______________________________________________________________
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DONOR SPECIFIC
Have you ever been a Sperm Donor before? ____ yes ____ no
If so, when? ___________________
Where (please list clinic/s you had donations at and there phone numbers)?
_______________________________________________________________________
_______________________________________________________________________
Have you ever gotten women pregnant before? ____ yes ____ no
If so, when and how many pregnancies? _______________________________
Would you speak with the recipient couples but not meet them in person?
____ yes ____ no
Would you share non-identifying letters? ____ yes ____ no
Would you meet in person with the recipient couple? ____ yes ____ no
Would you exchange identifying information? ____ yes ____ no
Would you like to meet any children who may result from your Sperm donation, once they reach
18 years of age in the presence of a Psychologist?
Would you consider donating your Sperms on more than one occasion?
____ yes ____ no
If yes how many times_________________________
Would you be willing to update your records with any important medical information that might
impact the offspring from your donation? ____ yes ____ no
Did your mother take diethylstilbestrol (DES) or any other prescription drug when she was
pregnant with you? ____ yes ____ no
If yes, please explain: ____________________________________________________
______________________________________________________________________
Have twins or multiple births occurred in your family? ____ yes ____ no
If yes, explain and list relation to you: ________________________________________
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PERSONAL HEALTH HISTORY
Do you currently have allergies? ____ yes ____ no
If yes, what are they due to? _______________________________________________
Please list specific substances and reaction(s) produced below:
Substance Reaction
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Did you have any childhood allergies that you have outgrown? ____ yes ____ no
If yes, please explain: ____________________________________________________
______________________________________________________________________
How is your vision, without glasses? ____ poor ____fair ____good ____excellent
Your vision is about: 20/_________
Do you wear glasses or contact lenses? _____________________________________
Are you: ____ nearsighted ____farsighted ____ other
If other, explain: ________________________________________________________
Do you have normal hearing? ____ yes ____ no
If no, explain: __________________________________________________________
Condition of your teeth: ____ poor ____ fair ____ good ____ excellent
How is your diet? ________________________________________________________
Do you have special eating habits (e.g. vegetarian)? ____________________________
Do you exercise? _______________________________________________________
What type of exercise and how often per week? _______________________________
______________________________________________________________________
Do you smoke cigarettes? ____ yes ____ no
If yes, how often and how many? _________________________________________
Do you drink alcohol? ____ yes ____ no
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If yes, how much and how often? ___________________________________
When was the last time you used recreational drugs, and which drug?
___________________________
Do you drink caffeinated beverages? ____ yes ____ no
If yes, how much and how often per day? _____________________________________
Are you currently taking any medication prescribed by a physician? ____ yes ____ no
If yes, please list what medications you are taking, for what condition, how long and daily dosage:
_____________________________________________________________________________
_______________________________________________________________
Have you ever had major radiation or x-ray exposure? ____ yes ____ no
Have you ever had a blood transfusion? ____ yes ____ no
If yes, when and why? ____________________________________________________
______________________________________________________________________
Have you ever been hospitalized? ____ yes ____ no
If yes, when and for what reason? _________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Have you ever had any facial plastic or reconstructive surgery? ____ yes ____ no
If yes, what, when and why?
_________________________________________________________________
Have you been treated for any sexually transmitted diseases in the last three years?
____ yes ____ no
If yes, please list all sexually diseases that you have been treated for:_______________
_____________________________________________________________________________
_______________________________________________________________
When was the last time you were treated? ___________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
How many times have you been treated? ____________________________________________
_____________________________________________________________________________
Has your partner ever been treated for any sexually transmitted diseases? _________________
If yes, please list all sexually transmitted diseases that they been treated for:________________
_____________________________________________________________________________
_____________________________________________________________________________
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When was the last time they were treated? __________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
How many times have they been treated? ___________________________________________
_____________________________________________________________________________
Have you ever been tested for cystic fibrosis? _____yes ______no
If so, what were the results?
Are you a carrier? _____ yes _____ no
Have you ever had any major illnesses such as mononucleosis, pneumonia, hepatitis amoebic
dysentery, etc? ____ yes ____ no
If yes, what illnesses and when? __________________________________________________
Any current, chronic medical problems or conditions? ____ yes ____ no
If yes, explain: ________________________________________________________________
In the past five years have you had any exposure to any chemicals, drugs or
gasses? ____ yes ____ no
If yes, explain:_______________________________________________________________
Have you excessively been exposed to Asbestos or Asbestos products?_________________
If yes, explain:_______________________________________________________________
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FAMILY HISTORY
Please describe your family members by the following physical characteristics. For Siblings
please circle whether they are Male or Female:
Hair Color Eye Color Complexion Height Body Type Vision
Father
Mother
Sibling M /F (1)
Sibling M /F (2)
Sibling M /F (3)
Sibling M /F (4)
Sibling M /F (5)
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
** If you do not know just leave blank.
Please be as specific as possible.
Age (if living) Children Age at Time of Death Cause of Death
Maternal Grandfather -------------
Maternal Grandmother -------------
Paternal Grandfather -------------
Paternal Grandmother -------------
Father -------------
Mother -------------
Sibling (1)
Sibling (2)
Sibling (3)
Sibling (4)
Sibling (5)
Has any member of your family, including yourself, had problems or defects of any kind?
____ yes ____ no
If yes, explain: __________________________________________________________
______________________________________________________________________
Are there any genetic diseases that run in your family? ____ yes ____ no
If yes, what are they? ____________________________________________________
______________________________________________________________________
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Please look through the list of the following medical problems and indicate which ones
you or one of your relatives have had: In the “Grandparents” box please indicate if they are
“Paternal” or “Maternal” Grandparents with the abbreviation of PGF, PGM, MGF or MGM:
Medical Condition You Father Mother Sibling (#) Grandparents Aunt Uncle Cousin
Blood:
Anemia
Immune Deficiency
Leukemia
Sickle Cell Anemia
Hemophilia
Other
Heart:
Heart Disease
Heart Attack
Stroke
Heart Disease from
Birth
Harding of Arteries
Other:
Medical Condition:
HIV
Hepatitis A, B or C
Liver Disease
Cancer
Colon Cancer
Breast Cancer
Intestinal Cancer
Stomach Cancer
Lung Cancer
Cystic Fibrosis
Crohn’s Disease
Ulcerative Colitis
Other
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Medical Condition You Father Mother Sibling Grandparents Aunt Uncle Cousin
(#)
Respiratory
Asthma
Hay fever
Pneumonia
Tuberculosis
Emphysema
Other
Sight/Sound/Smell
Blindness
Color Blindness
Glaucoma
Cataracts before the age of
50
Deafness before the age of
60
Deformity of the Ear
Deviate Septum
Other
Metabolic/Endocrine
Hypo-Glycemia
Diabetes
Hyperactivity
Adrenal Dysfunction or
Disorder
Thyroid Cancer
Goiter
Other
Mental Health
Clinical Depression
Manic Depression
Anxiety
Schizophrenia
ADD
ADHD
Other
Neurological
Migraines
Epilepsy
Cerebral Palsy
Multiple Sclerosis
Mental Retardation
Senility before the Age of 50
Spinal Chord Disorder
Hyper-Cephalus
Huntington’s Chorea
Wilson’s Disease
Gaucher’s Disease
Other
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Medical Condition You Father Mother Sibling (#) Grandparents Aunt Uncle Cousin
Urinary
Kidney Disease
Rectal Disorder
Other
Genital/Reproductive
System
Ovarian Cysts
Cancer of the Cervix
Cancer of the Ovaries
Uterine Fibroids
Hypo-Spadiasis
Prostate Cancer
Undescended Testicles
Other
Skin
Acne
Eczema
Pigmentation Disorder
Skin Cancer
Other
Muscles/Bones/Joints
Arthritis
Gout
Osteoporosis
Muscular Dystrophy
Lupus
Dwarfism
Scoliosis (Deformity of
the Spine)
Other
Addictions/Disorders
Alcoholism
Drug Abuse
Eating Disorder
Other
Gastro-Intestinal
Ulcer
Duodenum
Gall Stones
Other
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Sperm Donor Inc. FDA Questionnaire
In order to protect recipients of donated tissues, the FDA has mandated infectious disease Responses
testing. To protect all of our patients, including prospective recipients, SIRM asks that you
respond to the following screening questions. Thank you for your cooperation.
YES NO
1. Have you or your partner ever had a history of or been diagnosed with Hepatitis B,
Hepatitis C, or Hepatitis of unknown etiology (cause)?
2. Have you, in the preceding 12 months, been exposed to
known or suspected HIV, HBV, and/or HCV-infected blood through percutaneous
inoculation (e.g. needle stick), or through contact with an open wound, non-intact skin,
or mucous membrane.
3. Have you in the preceding 12 months had close contact with a person
who had clinically active hepatitis (e.g. living in the same household,
sharing of kitchen and bathroom facilities)?
4. Have you or your partner had a positive test for or treatment for syphilis
in the past 12 months?
5. Do you have a degenerative or infectious neurological disease, such as
Creutzfeldt-Jakob disease, multiple sclerosis, Alzheimer’s disease,
encephalitis of unknown etiology?
6. Have you ever received pituitary derived human growth
hormone?
7. Have you or your partner received non-therapeutic injected drug use
within the preceding five years? (Including intravenous, intramuscular,
or subcutaneous injection.)
8. a. If female answering: Has your partner engaged in anal or oral sex with
another man at any time in the last five years.
8.b. If male answering: Have you engaged in anal or oral sex with another
man at any time in the last five years?
9. Do you or your partner have a clotting disorder where you have ever
received Factor VIII or Factor IX or other clotting factors which were
not heat activated or virally inactivated?
10. Have you or your partner had any evidence of HIV infection?
a. Have you or your partner had unexplained weight loss?
b. Have you or your partner unexplained night sweats?
c. Have you or your partner had unexplained fever for more than 10
days?
d. Have you or your partner had unexplained persistent diarrhea?
11 Have your or your partner been inmates of a correctional facility for 72
consecutive hours or longer within the preceding 12 months?
12. Have you, within the previous 12 months, been with a heterosexual
partner that was HIV positive?
13. Have you or any partner of the last 12 months been engaged in
sex for money or drugs at any time in the preceding five years.
14. Have you had significant exposure to a substance that may be transferred
in toxic doses, such as lead, mercury and/or gold?
15. In the last 12 months, have you received a tattoo or other skin piercing in
which shared instruments were not sterilized between uses?
16. Have you, within the preceding six months, received a bite form an
animal suspected of having rabies?
17. Have you received a blood transfusion in the previous 12 months?
18. Have you ever had exclusion from a blood donation for reasons of
infectious disease?
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19. Have you or your partner ever has a sexually transmissible disease,
including herpes simplex type 2?
20. Have you had more than one sexual partner in the last 12 months?
21. Have you had an occupation with increased risk of radiation or chemical
exposure; or known exposure to radiation or chemicals?
22. Have you, or some one who is a close contact, had a smallpox
vaccination in the last 3 months?
a. If yes, date of vaccine: ________; and did the scab come off on its own?
b. Did you have a reaction to the vaccine, or develop lesions if a close
contact was the one vaccinated?
23. Have you been diagnosed with or been exposed to West Nile Virus
within the last month?
24. Have you been treated for or suspected of having Severe Acute Respiratory
Syndrome (SARS) within the last month?
25. Have you had close contact with someone having or suspected of having
SARs within the last 14 days?
26. Have you resided in or traveled to an area affected by SARS within the last
14 days?
27. Have you had a transplant or other medical procedure involving exposure to
live cells, tissues, or organs from an animal?
28. Has an intimate contact of yours had a transplant or other medical procedure
involving exposure to live cells, tissues, or organs from an animal? (Sexual
partner, sharing of razors, toothbrushes, health care or lab workers with repeated
percutaneous, mucosal or other direct exposure.)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - -
The above information is true and correct to the best of my knowledge.
______________________________ ___________________________
Patient/Donor Signature Date
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Thank you for taking the time to complete this application.
I declare that all of the above information and statements made regarding myself and my family’s
health history are true and correct. This Sperm Donor Health History and Background form has
been completed without perjury.
Signature: ____________________________________ Date: __________________
* When sending in your application, please include a copy of your
driver’s license so we can verify you are who you say you are, and fax it in to
(208) 895-8072.
If you need to mail your application in, please mail it to:
SDI
PO Box 533
Meridian, ID 83680-0533
Thank you for your application and we look forward to receiving it.
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Donor Acknowledgement Sheet
Name: _________________________Phone______________________
Donors Signature:________________________________________
Please initial each acknowledgment below:
_______ Donor is not suffering from any medical/clinical disorders (depression, anxiety etc.)
_______ Donor is drug free and understands that they will be drug tested.
________Donor understands that they may need to travel 5-8 days (all expenses paid) for
donation process l and possibly 1-2 days in the beginning.
________ Donor understands that they will be signing into a legal contract with selected couple.
________ Donor understands they must take and pass Psychological Evaluation (paid by
Recipient Couple).
________ Donor understands they must take and pass Medical Screening (paid by Recipient
Couple).
_________Donor understands she will be tested for diseases such as HIV and Hepatitis and any
other test doctor request.
________ Donor must have a high level of responsibility to meet the time requirements of the
program and call into SDI after each clinical visit or with any new information that pertains to this
procedure.
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SDI
www.spermdonorsinc com
Sperm Donors Inc.
Website Release Form
By signing below I give permission for Sperm Donors Inc. and their sister agencies to list
on their web site/s selected pages from my application that I filled out to be a donor
(except such information as my last name, e-mail, address and phone number). I also
give my permission to put up on their web sites any/all pictures of me that I have
submitted to them of their choosing.
___________________________________________________
Signature
__________________________________________________
Print Name
___________________________________________________
Date
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