Application Form - Egg Donor

Egg Donor Application

Please complete this form to the best of your ability. We will contact you within 24 hours after submission.
Name:*

First NameLast Name
E-mail:*
example@example.com
Re-type E-mail:*
example@example.com
What is your phone number?*

Area CodePhone Number
When is the best time to reach you?*
Preferred method of communication?*
Address:*

Street Address

Street Address

CityState / Province

Postal / Zip Code
Birth Date:*
Month/Day/Year
Age:*
Are you a U.S. citizen or US permanent resident?*
What is your relationship status?*
How did you hear about us?*
Please explain how long you have considered being an egg donor and the reasons why?*
Have you started the process with another agency/person but were told you didn't qualify? If yes, what were the reasons?*
Would you be willing to travel for IVF appointments and the retrieval?*
All of the costs will be covered by your future Intended Parent(s)
Physical Traits
What is your height?*
Feet and inches
What is your weight?*
In pounds. *We aren't being intrusive here; fertility clinics specify an acceptable range for Body Mass Index (BMI) based on height and weight.
What is your eye color?*
What is your natural hair color?*
What is your blood type?
Describe your ethnicity?*
Medical History
Do you have a history of any surgeries or medical treatments?*
Tell us about any allergies or sensitivities you suffer from?*
Are you vaccinated against COIVID-19?*
Are you currently taking any prescribed medications? Which ones?*
Do you currently smoke cigarettes or use tobacco products?*
Do you currently vape?*
Do you currently use marijuana products?*
Do you reside with anyone who smokes cigarettes, cigars, vapes, or smokes marijuana products?*
We are asking about your daily exposure to second hand smoke.
Do you use any illegal drugs?*
How often do you drink alcohol?*
Are you adopted? *
Reproductive Health History
How old were you when you started your period?*
Is your menses regular? How many days between your cycles?*
Are you using any form of birth control to prevent pregnancy? If yes, which kind? *
Please write n/a if this doesn't apply.
Do you have children? If yes, how many?*
Please write n/a if this doesn't apply.
Have you been an egg donor before?*
If yes, please tell us about your experience:
Have you had fertility testing done?

YesNo
Have you or anyone in your close family experienced infertility? If yes, please explain.*
Are you willing to administer self-injectable medications? *
Mental Health History
Please mark any mental health conditions you currently suffer from:*

NoneAnxietyAnorexiaBi-polarBulimiaMajor DepressionOCDSchizophreniaSubstance Abuse IssuesOther
Does/did your biological father suffer from any of the following*

NoneAlcoholismSubstance AbuseAnxietyDepressionI don't know
Does/did your biological mother suffer from any of the following*

NoneAlcoholismSubstance AbuseAnxietyDepressionI don't know
Do any of your siblings suffer from any of the following

NoneAlcoholismSubstance AbuseAnxietyDepressionI don't know
Education and Occupation
What is your highest education level?*
What was/is your field of study or area of expertise?*
Are you currently a student?*
Are you currently employed?*

YesNo
Where do you work?
What is your job title?
How many hours per week do you work?
Describe a typical day at work. What activities do you do? Are you at a desk job or is the work physical?
Does your employer allow flexibility to take time off from work to attend doctor appointments and other appointments required for being an egg donor?*

YesNoI don't have outside employment
Have you ever been arrested or convicted of a crime? If yes, please explain:*
Preferences
Describe the type of Intended Parent(s) that you hope to match with?*
Do you want your contact information and identity shared with the intended parent(s) to give their child if he/she shows interest in meeting you?*
Describe your communication preferences with the intended parent(s) before the egg retrieval?*
Describe your communication preferences with the Intended Parent(s) after the egg retrieval?*
Do you have an expectation that you will be involved in the child's life in some way in the future?*
Do you want your identity and information shared with the child?*
How would you feel if this child wanted to meet you at some future point?*
Please share with us more about your situation and any questions you have:*
Digital Signature

By typing your name below, you acknowledge that you are signing this document electronically. By signing this document electronically you certify that your answers are correct and complete to the best of your knowledge.
Digital Signature:*
Date:*
Should be Empty:

Egg Donor Application

Physical Traits

Medical History

Reproductive Health History

Mental Health History

Education and Occupation

Preferences

Digital Signature