Egg Donor Questionnaire
I. Physical Information
Tell us about yourself
Full Name: (This information is private and will not appear on your profile)
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Mobile Number: (This information is private and will not appear on your profile)
*
Format: (000) 000-0000.
Email: (This information is private and will not appear on your profile)
*
Where the confirmation will be send to
Home Address (This information is private and will not appear on your profile. It will only be used for shipping medications)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If you were referred to us by anyone, please list their name.
Are you a US Citizen or have permeant residency?
*
Yes
No
Do you have a VISA?
Yes
No
Compensation request. The recommended compensation for first-time donors is $10,000, but you’re welcome to request an amount that you feel comfortable with. Please let us know your requested compensation so we can include it in your profile. Please note, you can donate up to 6 times per ASRM guidelines and compensation increases with each donation.
*
Natural Hair Color
*
Black
Brown
Blonde
Red
Hair Type
*
Straight
Curly
Wave
Eye Color
*
Blue
Green
Hazel
Brown
Other
Height
*
Weight
*
Blood Type
*
Race
*
Ethnicity
*
Complexion
*
Fair
Olive
Medium
Dark
Are you of Jewish (genealogical) heritage?
*
Yes
No
Are you adopted?
*
Yes
No
If yes, do you know your family's medical history?
*
Yes
No
N/A
Corrective Dental
*
Yes
No
Freckles
*
Yes
No
Hand preference
*
Right
Left
Ambidextrous
Religious Affiliation
Occupation
*
Education
Do you have any college background or currently enrolled?
*
Yes
No
Highest level of education completed
*
University Names
*
Major(s)
*
GPA
ACT Score
SAT Score
What is your favorite subject?
Do you speak multiple languages? If so, please list.
Do you have a learning disability? If yes, please explain.
*
Health & OB-GYN
Have you ever been pregnant?
*
Yes
No
If yes, how many children do you have? If none list N/A.
*
Are you currently breastfeeding?
*
Yes
No
Have you ever had an abortion?
*
Yes
No
What method(s) of birth control are you currently using?
*
Has anyone in your family given birth to multiples?
*
Yes
No
Overall Health Condition
*
Date of your last pap smear. (If none put N/A)
*
What were the results of your last pap smear?
*
Do you have both overies?
*
Yes
No
At what age did you first experience your menstrual cycle (period)?
*
Is your menstrual cycle regular? If no, please explain.
*
Do you currently have or have you ever had any sexually transmitted infections (STIs)? If so, please specify if they were treated.
*
Do you have any allergies? If yes, please explain.
*
Do you currently take any prescription or over-the-counter medications? If yes, please explain.
*
Do you or anyone in your family have genetic disorders?
*
Please list any health conditions or concerns for you or anyone in your family. If none, please type N/A.
*
Have you ever tested positive for HIV/AIDS?
*
Yes
No
Have you ever seen a psychiatrist, psychologist, or any other mental health professional?
*
Yes
No
Have you ever been prescribed psychiatric medication(s)?
*
Yes
No
Have you ever been hospitalized due to a psychiatric issue?
*
Yes
No
Have you received a COVID-19 vaccine? If yes, please specify the type of vaccine (e.g., Pfizer, Moderna, Johnson & Johnson) and the dates of vaccination, if known.
Are you currently treating any diseases? If so, please list.
*
Have you gotten any tattoos in the past 12 months?
*
Yes
No
Have you had any piercings in the past 12 months?
*
Yes
No
Have you ever received a blood transfusion?
*
Yes
No
Have you undergone any surgeries? If so, please list.
*
Do you drink coffee? How often (daily or weekly)
Do you drink alcohol? How often (daily or weekly)
Do you smoke, vape, or use marijuana? (Please note, you must be able to pass a drug screen to be eligible)
*
Personality
Tell us a bit about your personality! How would your friends or family describe you? How would you describe yourself in a few words—outgoing, thoughtful, creative? Are you more of an introvert or extrovert—or somewhere in between? We'd love to know what makes your personality unique! Give us a glimpse into your personality!
*
Do you consider yourself athletic? Please share any sports or physical activities you've participated in, such as dance, gymnastics, roller skating, snowboarding, or team sports like softball or basketball. Do you enjoy staying active? Let us know if you've done any sports or fun activities like dancing, gymnastics, skating, or team sports!
*
Do you have any musical talents or experience playing instruments or singing?
*
What are your hobbies?
Favorite Color
Favorite Foods
What would you like to say to the intended parents on their journey? Why does being an egg donor feel meaningful to you?
*
Have you been an egg donor before? If yes, how many cycles have you completed?
*
Family History
YOU'RE APPLICATION IS ALMOST COMPLETE!
What is your mother’s current age? (If she has passed away, please share her age at the time of her passing)
*
Hair Color
*
Blonde
Brown
Black
Red
Eye Color
*
Blue
Green
Hazel
Brown
Other
Height
*
Education & Occupation
*
What is your father's current age? (If he has passed away, please share his age at the time of his passing).
*
Hair Color
*
Blonde
Brown
Black
Red
Eye Color
*
Blue
Green
Hazel
Brown
Other
Height
*
Education & Occupation
*
What is your maternal grandfather's current age? (If he has passed away, please share his age at the time of his passing).
*
Hair Color
*
Blonde
Brown
Black
Red
Eye Color
*
Blue
Green
Hazel
Brown
Other
Height
*
Education & Occupation
*
What is your maternal grandmother's current age? (If she has passed away, please share her age at the time of her passing).
*
Hair Color
*
Blonde
Brown
Black
Red
Eye Color
*
Blue
Green
Hazel
Brown
Other
Height
*
Education & Occupation
*
What is your paternal grandfather's current age? (If he has passed away, please share his age at the time of his passing).
*
Hair Color
*
Blonde
Brown
Black
Red
Eye Color
*
Blue
Green
Hazel
Brown
Other
Height
*
Education & Occupation
*
What is your paternal grandmother's current age? (If she has passed away, please share her age at the time of her passing).
*
Hair Color
*
Blonde
Brown
Black
Red
Eye Color
*
Blue
Green
Hazel
Brown
Other
Height
*
Education & Occupation
*
How many siblings do you have in total? Please specify how many are brothers and how many are sisters.
*
Signature
Time to show us your smile! Please upload your favorite photos. Be sure to include a full-body shot, and feel free to add baby, childhood, and family photos. These really help intended parents connect with you and tend to stand out more.
If you would like to send additional photos later, we can connect and send them via email or text.
Your Privacy Comes First
Your trust means everything to us. All information you share in this form is completely confidential and will never be shared with anyone outside of the intended process without your clear permission. We're here to support you every step of the way—with care, respect, and your privacy at the heart of it all.
File Upload
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
File Upload
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Print Form
Submit Form
Submit Form
Should be Empty: