Egg Donor Application
Please complete this form to the best of your ability. We will contact you within 24 hours after submission.
Name:
*
First Name
Last Name
Language Preference for Assessment
English
Spanish
E-mail:
*
example@example.com
Re-type E-mail:
*
example@example.com
What is your phone number?
*
-
Area Code
Phone Number
When is the best time to contact you?
*
Is it okay to leave a detailed message on this phone?
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Yes
No
Preferred method of communication?
*
Phone Call
Text
Email
Address:
*
Street Address
Street Address
City
State / Province
Postal / Zip Code
Birth Date:
*
-
Month
-
Day
Year
Date Picker Icon
Age:
*
Are you a U.S. citizen or US permanent resident?
*
Yes
No
Have you ever been arrested or convicted of a crime? If yes, please explain:
*
Emergency Contact:
*
First Name
Last Name
Emergency Contact Phone Number:
*
-
Area Code
Phone Number
Who can we thank for referring you?
*
Facebook
Google/Internet
Friend
Stephanie Gonzalez
Fertility Clinic
Attorney
Craigslist
Word of Mouth
Event/Conference
Other
Have you been an egg donor before?
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Yes
No
I applied but did not meet the requirements
If yes, please tell us about your experience:
Please explain how long you have thought about being an egg donor for and why?
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Have you ever started the process with another agency/person but were told you didn't qualify? If yes, what were the reasons?
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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)
Social History
What three (3) words best describe your personality?
*
What are your interests/hobbies?
*
Do you have any favorite past times? What sports do you play? What TV shows do you like?
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Medical History
What is your height?
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Feet and inches
What is your weight?
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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 ethnic background?
*
Are you currently taking any prescribed medications? Which ones?
*
What kind of birth control are you currently using? How are you preventing pregnancy?
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Birth Control pill
Condoms
Mirena IUD
Paraguard IUD
Other IUD
Implanon
Diaphragm
Depo Provera shot
None-Tubes are tied
Partner had Vasectomy
Pull out method
None
How many children do you have?
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Please write n/a if this doesn't apply.
Have you or anyone in your close family experienced infertility?
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Myself
Sibling
Mother
Father
Maternal or Paternal Grandfather
Maternal or paternal Grandmother
Are you willing to administer self-injectable medications?
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Yes
No
Please mark any mental health conditions you currently suffer from:
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None
Anxiety
Anorexia
Bi-polar
Bulimia
Major Depression
OCD
Schizophrenia
Substance Abuse Issues
Other
Does your biological father suffer from any of the following
*
Alcoholism
Substance Abuse
Anxiety
Depression
Does your biological mother suffer from any of the following
*
Alcoholism
Substance Abuse
Anxiety
Depression
Do you suffer from any medical/physical conditions including sexually transmitted diseases? Please explain:
*
Some major disqualifiers include abnormal pap-smears, diabetes, irregular menstrual cycles, genetic disorders, etc.
Does your family have a history of mental or physical health abnormalities? If yes, please explain.
*
Or any other genetic disorders that may run in your family.
Do you smoke cigarettes?
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Yes
No
Do you vape?
*
Yes
No
Do you use marijuana products?
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Yes
No
Are you exposed to second hand smoke by way of cigarettes, cigar, vape, or marijuana?
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Yes
No
Do you use any illegal drugs?
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Yes
No
It's complicated
How often do you drink alcohol?
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Never
1-2 drinks per day
1-2 drinks per week
1-2 drinks per month
Are you vaccinated against COIVID-19?
*
Yes
No
Education and Occupation
Who do you currently reside with?
*
Are you currently a student?
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Yes
No
Highest level of education:
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High School
Some college
Bachelor's degree
Master's degree
Technical School
Cosmetology/Beauty
Other
Are you currently employed?
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Yes
No
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?
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Yes
No
I don't have outside employment
Are you currently receiving public assistance (food stamps, welfare, Medicaid, etc)?
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Yes
No
If yes, which programs are you currently receiving assistance (mark all that apply)?
Medicaid
AHCCCS (Arizona)
Food Stamps
Cash Assistance
HUD/Section 8 Housing
Other
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:
*
Submit
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