Hearts Milk Bank Donor Questionnaire and Consent Form

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1. Questions about you and your family

Please note: The Hearts Milk Bank is only able to accept donations of breastmilk from UK residents who are registered with UK healthcare providers and have an NHS number.
 

Are you a UK resident?
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Are you registered with a GP? *

 

Please select your UK county. If you are not in one of the counties listed below you may not be able to donate to the Hearts Milk Bank at this time. Please check www.ukamb.org for details of your nearest milk bank. *

 

Please enter your details below.

If you would like us to collect the milk from your home, please enter your what3words code, to allow our couriers to find your address. You can leave this blank if you are donating milk stored in a hospital. You can find your code at https://what3words.com/
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Status *

 

What is your date of birth? *

   DD/MM/YYYY