Donor Registration Form – Jigsaw DNA Connect

(08) 9228 2647
jigsawdna@jigsaw.org.au

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If you prefer a paper form, download it here.

Donors Registration Form

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Donors Details
Title*
- Mr
- Mrs
- Ms
- Mx
- Dr
Gender*
- Male
- Female
- Non-binary
Surname (family name)*
Given name(s)*
Maiden name (if applicable)
Other surnames (if applicable)
Date of birth*

DD
MM
YYYY
Place of birth (including state, or if born outside Australia, country)*
Contact Details
Address*
Suburb*
State*
Postcode*
PO Box Address
Primary Contact Phone Type*
Primary Phone Number*
Secondary Contact Phone Type
Secondary Phone Number
Can we leave a message identifying Jigsaw DNA at these numbers?
Mobile
- Yes
- No
Home
- Yes
- No
Work
- Yes
- No
Email*
Donation Information
If you donated at more than two clinics please give details in additional information section at the end of the form
Type of donation*
- Sperm
- Egg
- Embryo
Date of Donation
Date Format: DD slash MM slash YYYY
Donor Code
The donor code is essential for matching. You can contact the clinic where the donation took place to ask for non-identifying information about your offspring and obtain your donor code.
Donor Code Unknown
- Yes
If you do not have your code, would you like Jigsaw to contact the clinic and ask for your donor code?
- Yes
- No
Voluntary Register Number (previously registered to the Heath Department)
Alternatively, please download a Donor Code Form if you wish to contact the clinic yourself to obtain your code.
Name and address of FIRST Clinic / Hospital / other facility where donation occurred (if known)*
Clinic Unknown
- Yes
Do you have information about how many offspring were born using this donation?
- Yes
- No
If Yes, how many gender known?*
Have you had any contact with your donor offspring?*
- Yes
- No
Have you had any contact with any of their family?*
- Yes
- No
Comment
Voluntary Register Number
( those previously registered with the Health Department )

Donation Information (only complete if you donated at more than one clinic)
Type of donation
- Sperm
- Egg
- Embryo
Date of donation (if known)

DD
MM
YYYY
Date Unknown
- Yes
Donor Code
The donor code is essential for matching. You can contact the clinic where the donation took place to ask for non-identifying information about your offspring and obtain your donor code.
Donor Code Unknown
- Yes
Alternatively, would you prefer Jigsaw DNA to contact the clinic to ask for your donor code?
- Yes
- No
Name and address of SECOND Clinic / Hospital / other facility where donation occurred (if known)
Do you have information about how many offspring were born using this donation?
- Yes
- No
If Yes, how many?
Have you had any contact with your donor offspring?
- Yes
- No
Have you had any contact with any of their family?
- Yes
- No
Comment
Additional Information (if additionali Clinics / Hospitals were used, please add the information here)
Additional Information
Who are you searching for? (You may select more than one)*
- Offspring
- Offspring's parents
- Information only
- Don't know / not sure
DNA Testing
Have you undertaken any DNA tests?
- Yes
- No
Can we leave a message, identifying Jigsaw DNA, at these numbers?
Mobile*
- Yes
- No
Home*
- Yes
- No
Work*
- Yes
- No

What happens if there is a match
We will contact each person and discuss their wishes and how they want to proceed. Some people may just want to leave or exchange information, some may want full contact. If a match is made you will need to provide identification.

Your contact details will not be released without your consent.
Remember to update your contact details if they change.
Authority
I give permission for the information in this registration form to be shared with any government body authorised to manage the Donor and Offspring Register.*
- Yes
- No
I give the Donor and Offspring Register staff permission to contact the fertility clinic or medical practitioner where donation or treatment occurred if necessary.*
- Yes
- No
Your Full Name*
Signature
Reset

You can use your mouse to sign if you are not on a touch screen. If you prefer to download the form, then sign and email or mail it to us, you can still submit and a completed copy of the form will be emailed to you.
Date*

DD
MM
YYYY
Comment
Please let us know how you learned about the Donor and Offspring Register
How did you learn about this register?
- Jigsaw Website
- Internet Search
- Clinic
- Brochure
- Doctor
- Facebook
- Instagram
- Phone book
- Dept. of Health
- Friend
- Family
- Other
Name
This field is for validation purposes and should be left unchanged.

We encourage you to use our services which are free and confidential, and available to all parties involved in donor conception.

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(08) 9228 2647
jigsawdna@jigsaw.org.au
176 Fitzgerald Street
Perth WA 6000

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