EN_ΘΕΛΩ ΝΑ ΓΙΝΩ ΔΟΤΗΣ ΩΑΡΙΩΝ

Questionnaire

Please answer the questions below so that we can get to know you better. They will help us get the necessary information about you before proceeding with the required tests, medical history, documents, etc.
Name:*

NameSurname
Date of birth (you must be 18 - 32 years old):*

DayMonthYear
Mobile phone number:*
Format: (000) 000-0000.
In case you want us to call you on a specific day and time please note:
E-mail:*
Address:*
Profession:
Nationality:*
Skin colour:*
Hair colour:*
Eye colour:*
Height:*
Weight:*
Are you familiar with the process of donating sperm? Have you ever been a donor?*

YesNo
Do you have children?*

YesNo
Are you taking any medicine/s?*

YesNo
If you are taking any medicine(s), please note:
Do you have some kind of anemia?*

YesNoI don't know
Do you have any health problem?*

YesNo
If any, please mention:
Have you had any surgeries and if so, which ones?
Who introduced you to us?
*

I have been fully informed about the privacy policy of Medimall Clinic (www.medimall.gr) and I consent to the management of the information I have voluntarily filled in.
Should be Empty:

Questionnaire