Donor Screening Date* First Name* Last Name* Address (Street, City and State)* Phone* Email* When is a good time of day for us to contact you? How did you hear about Mothers’ Milk Bank? Are you a Kaiser Permanente patient? YesNo Baby's Name* Baby's Date of Birth* Was the baby born preterm? YesNo If yes, how many weeks Is your baby in the hospital? YesNo If yes, Name of hospital and contact information Bereaved donor? YesNo Surrogate donor? YesNo Are you a previous donor? YesNo Are you donating milk collected before you contacted the milk bank? YesNo Please estimate amount of milk you can donate Approximate oldest date of milk Was the expressed milk stored in the freezer? YesNo If refrigerated first, how many days before moving it to the freezer? Has your milk been thawed, scalded or boiled? YesNo If yes, please explain: Were you, the baby, and other members of your household healthy during the time you collected this milk? YesNo If no, please explain: Do you plan to be an ongoing donor? YesNoUnsure Please leave this field empty.
