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Confidential Egg Donor Application
Please press the SAVE/SUBMIT button before exiting this application so your progress is saved. Once you have answered all of the questions and uploaded your photos, a Case Manager will walk you through the process and begin the process of Matching with you with one of our Intended Parent Clients.
Name
*
First Name
Last Name
Email
*
Confirmation Email
example@example.com
Phone Number (used to contact you with egg donor matches)
*
-
Country Code
-
Area Code
Phone Number
State of Residence
*
Address (used to match you with monitoring clinics)
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Birth Date
-
Month
-
Day
Year
Date Picker Icon
Current Date
-
Month
-
Day
Year
Date
Age
Marital Status
Single
Live-In Partner
Married
Legally Separated
Divorced
Other
Have you ever:
*
Rows
Yes
No
Filed for bankruptcy?
Given a child up for adoption?
Owe child support?
Been convicted of a crime?
Filed for divorce or legal separation?
Have any legal cases of claims pending?
Bio (tell the Intended Parents about yourself). What is your personality like, are you type A to type B personality, are you organized, what is your relationship with your family and friends, what are your passions, what are your achievements, what makes you amazing and special and why do you wish to donate?
*
0/1000
Please Take a Photo of Yourself Now.
Upload Your HeadShot
Upload Side Photo of Face
Upload Full Body Length Photo
Upload Childhood Photo
Upload Baby Photo
Upload Family
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Your Donation Preferences
Why are you interested in learning more about or becoming an Egg Donor?
*
0/400
What type of Egg Donation are you interested in?
*
Anonymous (you remain completely anonymous)
Semi-Anonymous (you video chat or speak with Recipients)
Known Donation (you meet and keep in contact with Recipients)
Open to either an Anonymous or Known Donation
Requested compensation for your next egg donation process? Why are you requesting this amount?
PLEASE EXPLAIN WHY YOU ARE REQUESTING THIS AMOUNT OF COMPENSATION
0/600
TRAVEL PREFERENCES (all travel expenses are arranged and pre-paid for you and a companion of your choice). Please select ALL of your preferences.
Local Donation (within 50 miles)
Travel within my State
Travel Donation within the USA
Travel Donation to other Countries
Other
How do you get around (walk, car, train, parents, friend)
Please explain how you get around locally
Your Egg Donation Experience
Prior Egg Donor?
*
New Donor
Experienced Donor
Have you completed any blood work for an agency or IVF Clinic within the past year?
*
Yes
No
Please provide the following information regarding any bloodwork completed with the past 12 months:
Rows
Date
Clinic / Lab
Results
Do You Have Copies of Your Results?
AMH
LH
FSH
GENETIC TESTING
Please list information for all completed egg donation cycles. Experienced Donors are typically compensated more with each successfully completed egg donation.
Rows
Date
Clinic
Agency
Compensation
No. of Eggs/Embryos
Pregnancy
1st Donation
2nd Donation
3rd Donation
4th Donation
5th Donation
Have you had an abortion?
Yes
No
Have you had any miscarriages?
*
Yes
No
Have you given birth to any children?
*
Yes
No
Please provide gender, age, health status for all children that you have personally given birth to without the use of any fertility drugs, IVF treatments, donor egg or Surrogacy.
Rows
Gender
Date of Birth
Medical Conditions
Alive / Deceased
1
2
3
4
5
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Personal
Race/Ethnicity (select ALL that apply).
*
Armenian
Asian
Pacific Islander
African American
African (Black)
African (White)
Caribbean/Islander
Caucasian/White
Eastern European
East Indian
Egyptian
Ethiopian
Eritrean
Ghanaian
Hispanic (Black)
Hispanic (White)
Jewish
Indeginous
Italian/Sicilian
Kenyan
Native American
Nigerian
South American
South Asian
Other
Maternal and Paternal Heritage (e.g. Mother is Chinese, Han or Father is 1/2 Korean, 1/2 Caucasian)
*
0/300
Paternal Heritage (e.g. 1/2 Chinese, 1/2 African American)
*
0/300
On average, how much water do you drink each day?
*
1-3 glasses
4-6 glasses
6-8 glasses
More than 8 glasses
Diet (please select ALL that apply):
*
I eat pork
I eat chicken or turkey
I eat red meat
I eat seafood
I eat diary (milk, yogurt, cheese)
I eat 4-6 different types of vegetables every day
I eat 1-3 different types of vegetables everyday
I eat a variety of fruit everyday
I eat legumes (beans, lentils, peas)
I eat a variety of nuts (walnuts, peanuts, sunflower seeds, pumpkin seeds, cashews, almonds) several times per week
I eat candy or desserts everyday
Other
Religious Affiliation
*
Not Religious/Spiritual
Amish
Asatru
Atheisim
Bahai
Baptist
Buddhism
Candomble
Catholicism
Christianity
Hinduism
Islam
Jainism
Jehovah's Witnesses
Judaism
Mormonism
Paganism
Taoism/Daoism
Pentacostal
Protestant
Presbyterian
Rastafarian
Santeria
Shinto
Seventh Day Adventist
Zoroastrianism
Your Physical Features
The majority of our Egg Donors are anonymous and photos are not always very clear so Intended Parents have to rely on your description of yourself in order to get a clear sense of who you are, what you look like and are you the right Egg Donor for that particular Intended Parent.
Height
*
Weight
*
Enter Height and Weight again to calculate your BMI (must be less than 30% to donate)
*
Blood Type
*
A
B
AB
O
Rh (-)
Rh (+)
I Don't Know
Skin Tone (Complexion)
*
Fair (burn easily)
Tan (reddish undertones)
Olive (golden undertones)
Light Brown
Medium Light Brown
Medium Brown
Medium Dark Brown
Dark Brown
Other
Do you or anyone in your immediate family have eczema? If yes please explain.
Natural Hair Color (without processing)
*
Black
Brown
Light Brown
Blonde
Red
Hair Texture (prior to any treatments)
*
Straight
Wavy
Curly
Tight Curls
Afro Curls
Is your hair thin, medium or thick (prior to any added extensions or treatments)?
*
Thin
Medium
Thick
Balding
Eye Color
*
Blue
Green
Hazel
Light Brown
Brown
Dark Brown/Black
Eye Shape (per request of several of our Egg Donors, we have provided several charts throughout this application for your reference. Please use the chart below to determine your eye shape. You may select more than option, e.g. wide set & almond).
*
Wide set
Close set
Almond
Down turned
Protruding
Deep set
Hooded
Asian (monolid)
Asian (double lid)
Please reference image above and select the shape that you feel most resembles your lips.
Thin Lower Lip
Oval Lips
Thin Upper Lip
Downturned Lips
Thin Lips
Large Full Lips
Small Lips
Sharp Lips
Uneven Lips
Your Build
Petite
Medium
Large
Please provide your Bust, Waist and Hip Measurements.
Bust/Waste/Hip in Inches or Centimeters
Please reference image above to select which you feel best describes your body type:
Slender
Athletic
Hourglass
Pear
Apple
Would you consider your buttocks
Small
Medium
Large
Please reference image below and select the shape that you feel most resembles the shape of your posterior:
Square (H shape)
Round (O Shape)
Upside Down Heart (A Shape)
Inverted (V Shape)
Round, full and sits very high ("bubble butt")
Are you:
Right Handed
Left Handed
Ambidextrous
Do you have any distinguishing features (dimples, birth mark, small waist, long legs, high cheekbones, full lips, athletic build, etc... )
0/300
Do you have any vision problems such as a stigmatism, wear glasses or contacts? If yes, please state your eye prescription.
0/300
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Academics
Please enter your school and work schedule (used to match you with a clinic)
Rows
School
Work
Other
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Please select ALL degrees completed and currently being studied:
*
High School/G.E.D
Vocational/Trade School
2-Year College Degree
Bachelor's Degree
Graduate Program/Degree
List all Degrees with area of study (Major/Minor) that you have completed or are currently studying. Also list the University/College where degree was completed.
*
e.g. Completed B.S.in Engineering at UCLA. Completing Master's in Business Administration at Columbia University
Tell us about your academic studies:
Rows
Name of College
Degree Studied
Dates Attended
G.P.A.
Under-Graduate
Under- Graduate
Graduate
Graduate
Have you ever been Accepted To or Enrolled In one or more of these Ivy League Universities or Top Ranked Universities/Colleges in the US & England? (select all that apply).
Stanford
Princeton
University of Chicago
Harvard
M.I.T.
Yale
Dartmouth
Columbia
University of Pennsylvania
Oxford University
Cambridge College
John Hopkins
Duke
Caltech
Northwestern
Brown
Cornell
Rice
Notre Dame
Vanderbilt
Washington University in St. Louis
Emory
Georgetown
U.C.--Berkeley
U.S.C.
Carnegie Mellon
U.C.--Los Angeles
Amherst
Wesleyan
Swarthmore
Georgetown
Tufts
University of Virginia
Williams College
Pomona College
University of Michigan--Ann Arbor
Wake Forest
Haverford College
Washington and Lee University
Boston College
McGill
University of Toronto
Other
Please list all awards, honors and scholarships that you have ever won:
0/600
Are you a member of M.E.N.S.A.?
*
No
Yes
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Please Bragg About Yourself
What are your talents (what are you good at)?
e.g. video gaming, design, organization, caligraphy, dance, coding, robotics, stylist(hair,/make up/clothes)
0/600
Do you speak any languages?
0/300
Please list any artistic, musical or vocal abilities:
include any instruments played
0/600
What are your career goals?
0/600
Where do you see yourself in 10 years both personally and professionally? What do you wish to accomplish in this life?
0/600
Please list any athletic abilities:
0/600
What are/was your favorite subject in school and why?
0/600
What are/was your strongest subject in school and why?
0/600
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Medical History
Medical history will be verified. Anything purposefully omitted may result in being dropped from the program. Please answer all questions thoroughly and honestly.
Have you ever been exposed to or tested positive for any of the following viruses: Ebola, Zika, Small Pox, H.I.V., Hepatitis B or Hepatitis C?
*
No
Yes
Not sure
Other
Vaccines: Please select all vaccinations that you have received within the past 10 years. Write in any vaccines that you have received but are not listed.
Rows
Yes
Date of Vaccination
Covid-19
Flu
MMR (Measles/Mumps/Rubella)
HPV
Hepatitis C
Hepatitis B
Tetanus
Tuberculosis
Smallpox
Malaria
Diphtheria
Meningococcal
Pneumococcal
Polio
Shingles
Whooping Cough
Please list all cities and countries that you have traveled to within the past 12 months:
Have you ever been a victim of abuse?
No
Yes, Physical Abuse
Yes, Sexual Abuse
Yes, Psychological Abuse
Other
Please answer the following questions below:
Rows
If Yes, please explain
No
Have you ever been hospitalized for mental illness?
Have you ever considered committing suicide?
Have you ever tried to intentionally hurt yourself?
Have you ever tried to hurt a child or baby?
Are you currently in counseling?
Have you ever had an eating disorder?
Are you currently in counseling or being treated for anxiety or depression? If yes, please explain:
Your Medical Conditions: please list all your current and past medical conditions:
Rows
Medical Condition
Date of Diagnosis
Treatment Prescribed
Result of Treatment
1.
2.
3.
4.
5.
6.
Your Surgeries
Rows
Type of Surgery
Reason for Surgery
Year Completed
Outcome of Surgery
1.
2.
3.
4.
5.
How many sexual partners have you been with in the past 5 years?
Medications: please list all medication that you have taken within the past 2 years:
Rows
Name of Medication
Dosage
Reason for Taking
Dates Taken
1.
2.
3.
4.
5.
6
Have you completed a Physical Exam within the past 2 years? If so, what was the name of the Doctor/Practice and what was the result of your exam?
Have you completed a GYN Exam (Pap Smear) within the past 2 years? If so, what was the name of the Doctor/Practice and what was result each exam?
When not on birth control, do you have a menstrual cycle (period) every 25-35 days?
*
Yes
No
Gynecological History. Have you or any family members (grandparents, aunts, uncles, brothers, sisters, 1st cousins) been diagnosed with the following:
Rows
If Yes, Please Explain
No
Infertility
Prior Cervical Surgery (LEEP, Cone Biopsy)
History of DES exposure
History of abnormal PAP smear
Prior uterine surgery
History of uterine malformation
History of uterus opening up too early
History of uterine, ovarian or breast cancer
Fibroids, PCOS or Endometriosis
Hysterectomy
Multiple or Late Trimester Miscarriages
Miscarriages, still births, or neonatal deaths
Neurological History. Have you or any family members (grandparents, aunts, uncles, siblings, 1st cousins) been diagnosed with the following:
Rows
Family Member
Age of Onset
Current Condition
Age of Death (if applicable)
ADD or ADHD
Autism / Asperger's
Learning disabilities
Mental Retardation
Paralysis or crippling disorders
Memory Loss or Dementia
Seizure or Epilepsy
Alzheimer's disease (AD)
Multiple sclerosis
Parkinson's disease
Migraines
Age-related issues
Psychological History. Have you or any family members (grandparents, aunts, uncles, siblings, 1st cousins) been diagnosed with any of the following:
Rows
Family Member
Age of Onset
Current Condition
Age of Death (if applicable)
Alcohol or Drug Addiction
Depression
Anxiety/Panic Attacks
Schizophrenia
Bipolar Disorder
Age-related issues
Have you or any family members (grandparents, aunts, uncles, siblings, 1st cousins) been diagnosed with the following:
Rows
Family Member
Age of Onset
Current Condition
Age of Death (if applicable)
Cancer
Lupus
Physical Malformation
Sickle Cell Anemia
Cystic Fibrosis
High blood pressure
Heart attack or Stroke
Osteoporosis
Arthritis
Allergies
Blood diseases
Diabetes (Type 1 or II )
Thyroid issues
Age-related issues
Kidney problems / diseases
Vision/Sight/Eye Problems
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Family History
Are you adopted?
*
No
Yes
Yes, but I know my family history
Please provide the number of each type of relative
Rows
Brothers
Sisters
Maternal Aunts
Maternal Uncles
Paternal Aunts
Paternal Uncles
Number of Relatives
Physical Characteristics (Family Members)
Rows
Eye Color
Hair Color
Height
Weight
Complexion
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Father
Mother
Brother
Brother #2
Brother #3
Sister
Sister #2
Sister #3
Please tell us about your family members:
Rows
Personality/Traits
Talents
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Father
Mother
Brother
Brother #2
Brother #3
Sister
Sister #2
Sister #3
Please complete the following table. Please do not put "natural" as a cause of death. If unknown, type "unknown".
Rows
Current Age
Health Issues
(If dead) Age of Death
(if dead) Cause of Death
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Father
Mother
Brother
Brother #2
Brother #3
Sister
Sister #2
Sister #3
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Fun Facts
Describe your personality:
0/400
Do you consider yourself introverted (reserved and quiet) or extroverted (outgoing and talkative)? Please explain:
0/400
What is an average day like for you?
0/400
Tell us about your favorites:
Rows
Color
Food
Dessert
Music
Artist/Band
Favorite
Tell us about your favorites:
Rows
Author
Book
Newspaper / Magazine
Blog
Movie
Favorite:
Tell us about your favorites:
Rows
Actor/Star
Season
Holiday
Sport(s) to Watch
Sport(s) to Play
Favorite:
What are your passions and hobbies? Do you volunteer?
0/400
Where have you traveled? Where do you still wish to travel? Why?
0/400
Whom do you admire most (living or dead) and why?
0/400
What famous person or public figure would you play in a movie and why?
0/400
What was your childhood like? Do you come from a big or small family?
0/400
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FDA QUESTIONNAIRE
Are you aware of any genetic or hereditary conditions within you or your biological family such as heart disease, cancer, alcoholism, physical deformities, neurological conditions?
*
Yes
No
Have you ever been diagnosed with Diabetes, High Blood Pressure or Sepsis?
*
Yes
No
Not sure
Have you ever had: (i). Any type of cancer, including leukemia; (ii). Any problems with your heart or lungs; (iii). A bleeding condition or a blood disease; (iv). Sexual contact with anyone who was born in or lived in Africa; (v). Received a dura mater (or brain covering) graft; (vi) Have any of your relatives had Creutzfeldt-Jakob disease?
*
Yes
No
Do either you or your parents drink more than 2 glasses of alcohol on a daily basis?
*
Yes
No
Have you ever been convicted of a misdemeanor or felony in the last 5 years? (Example DUI, DWI, Theft, Possession, etc.)
*
Yes
No
Have you ever been in juvenile detention, lockup, jail, or prison for more than 72 hours?
*
Yes
No
Have you ever used any of these prescription or recreational drugs in any form? Please select the names of the medication used. Select "Not Applicable" if you have not used any of these medications.
*
Not Applicable
Heroine
Adderall
Valium (Diazepam)
Ambien (Zolpidem)
Methadone
Cocaine
Morphine
Ecstasy
Molly (MDMA)
Methamphetamine
Soma (Carisoprodol)
Ketamine
Oxymorphone
Buprenorphine
Ativan (Lorazepam)
LSD
DMT
Ritalin
Xanax (Alprazolam)
Vicodin (Hydrocodone)
OxyContin (Oxycodone)
Clonazepam (Klonopin)
Other
Have you EVER taken any of these medications: Propecia© (finasteride) Accutane© (Amnesteem, Claravis, Sotret, isotretinoin) Soriatane© (acitretin) Tegison© (etretinate) Growth Hormone Insulin Hepatitis B Immune Globulin Unlicensed Vaccine usually associated with a research protocol?
*
Yes
No
Between 1980 and 1996, did you live in the following Western European countries (France, Germany, Austria, Austria, Spain, Bavaria, Belgium, Italy, Portugal) or Great Britain (the Channel Islands, England, Falkland Islands, Gibraltar, Isle of Man, Northern Ireland, Scotland, Wales) for more than 3 months?
*
Yes
No
In the past 12 months, have you had any of the following procedures: (i). Blood transfusion; (ii). Organ, tissue, or bone marrow transplant; (iii). Skin or bone graft; (iv). Contact with someone else’s blood; (v). Accidental needle-stick?
*
Yes
No
In the past 12 months, have you been diagnosed with or had sexual contact with anyone that has had any of the following (please select ALL that apply):
*
Not Applicable
Has tested positive or has been treated for Hepatitis B or C
Has or tested positive for the HIV/AIDS virus
Tested positive for Chlamydia, Trichomoniasis, or Genital Crabs within the past 6 months
Tested positive for Gonorrhea within the past 6 months
Ever tested positive for Syphilis
Had sexual contact with a male who has ever had sexual contact with another male
Takes drugs, money or other payment for sex
Hemophilia or has used clotting factor concentrates
Ever used needles to take drugs or steroids, or anything not prescribed by their doctor
Had Chagas’ disease or Babesiosis
Please verify that you are human
*
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