• Acorn Surrogacy Center

    Acorn Surrogacy Center

    3333 Michelson Dr., Suite 300, Irvine, CA 92612 TEL: 626 427 3000 Fax: 626 270 4578

  • Basic information 基本资料

  • Physical Description 生理描述

  • ETHNIC ORIGIN 種族血統

    (please be specific – French, Chinese, German, etc. 請詳細註明填寫. 例如: 法國人, 中國人, 德國人)

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  • Education 教育程度

  • 22. Do you have any learning disabilities? 您是否有任何学习障碍？  
       , please explain       * 

  • Donation History

  • 23. Have you ever been an egg donor? 您之前有捐过卵子吗？  
       , please explain      * 

  • Personality个性

  • Menstrual History 经期历史

     

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  • Pregnancy History怀孕历史

  • Health Information 健康资料

  • 47. Are you under a physician's care for any reason? 您现在有看任何医生吗？  
       , please explain       * 

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  • EXERCISE INFORMATION 運動情形

  • MEDICAL HISTORY 疾病歷史            

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  • FAMILY HISTORY 家庭歷史

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  • CONFIDENTIAL 保密資料

    The following information will be kept confidential 以下資料並不對外公開.

    Are you able to comply with the following requirements 您可以遵守以下的要求嗎?

  • No legal fees, psychological testing fees, medical testing fees or medical procedure fees will be charged to the applicant or her partner. 

    捐卵者不需要為律師、心理評估、醫療檢查及步驟付費。 

    I consent to being notified of any medical information discovered about me during the egg donation process.

    我同意被告知在捐卵過程中所發現的醫療資訊

     

    I AUTHORIZE THE RELEASE OF ANY NON-FICTIONAL INFORMATION AND PHOTOGRAPHIC MATERIAL ENCLOSED IN THIS APPLICATION.

    我允許資料和照片被使用(不包括姓名)

     

    I CERTIFY THAT ALL THE INFORMATION PROVIDED IS COMPLETE AND TRUE TO THE BEST OF MY KNOWLEDGE.

    我確認以上所有資料是完整而且正確的

     

  • Please type your full name      

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