Home
About Us
Recipient Information
Resources
Donor Information
FAQ
Process
Donor Comments
Donor Application Part I
Donor Application Part II
Donor Gallery
Login
Register
User Profile
Contact Us
Home
Donor Information
Donor Application
Donor Application
Step
1
of
7
14%
MyDonorID
I understand that as an egg donor, I would be required to take self-administered injections for approximately 20 days.
*
Yes
As an egg donor, I understand that the primary requirements for application are that I be a female, between the age of 21-29*, a non-smoker, non-drug user and that I am neither significantly overweight nor underweight for my height, and that I have some formal education beyond high school.
*
Yes
As an egg donor, I would be required to undergo a procedure under sedation to remove my eggs from my ovaries at the conclusion of my treatment.
*
Yes
As an egg donor, I understand that I would be required to keep approximately 10 different doctor's appointments throughout my treatment, many of which are between the morning hours of 8am and 10am.
*
Yes
I understand that egg donation is a very serious matter, and that the intended parents place a tremendous amount of trust in their egg donor to comply with instructions and to do everything possible to make eventual pregnancy a success.
*
Yes
I am currently living in New York, New Jersey, Connecticut or Pennsylvania
*
Yes
I have never donated previously or have done 6 or fewer cycles.
*
Yes
I have had zero or one miscarriages
*
Yes
Name
*
First
Middle
Last
Home Phone
*
Voicemail
OK to leave Voicemail
Work Phone
*
Voicemail
OK to leave Voicemail
Cell Phone
Voicemail
OK to leave Voicemail
Email
*
Enter Email
Confirm Email
Are you a United States citizen?
*
Yes
No
Do you have legal status to work in the United States?
Yes
No
If you not a citizen, please describe your current status (greencard, student visa, etc).
*
Date of Birth (mm/dd/yyyy)
*
MM slash DD slash YYYY
Height
*
Feet and Inches
Select Height
4'11"
5"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6"
6'1"
6'2"
6'3"
Weight
*
(in lbs)
Eye Color
*
Blue
Brown
Green
Hazel
Other
Natural Hair Color
*
Black
Blonde
Brown
Red
Other
Marital Status
*
Single
Married
Divorced
Widowed
Level of Education
*
Associate Degree
Bachelor's Degree
Graduate of Professional Degree
Some College
Other
Prefer Not to Answer
Have you ever been an egg donor
*
Yes
No
Previous Donations
Please list the clinic names and dates of prior extractions.
Number of Donor Cycles
*
1
2
3
4
5
6 or more
Name of Clinic
*
Date
*
MM slash DD slash YYYY
Name of Clinic
*
Date
*
MM slash DD slash YYYY
Name of Clinic
*
Date
*
MM slash DD slash YYYY
Name of Clinic
*
Date
*
MM slash DD slash YYYY
Name of Clinic
*
Date
*
MM slash DD slash YYYY
Name of Clinic
*
Date
*
MM slash DD slash YYYY
Name of Clinic
*
Date
*
MM slash DD slash YYYY
Information about previous pregnancies
Have you ever been pregnant?
*
No
Yes
Are you currently pregnant?
No
Yes
Are you currently breast-feeding?
No
Yes
Number of Pregnancies
0
1
2
3
4
5 or more
Number of Live Births
0
1
2
3
4
5 or more
Number of Miscarriages
0
1
Number of Abortions
0
1
2
3
4
5 or more
Please indicate whether you have had any of the following:
AIDS-HIV
Blood Transfusion
Chlamydia
Gonorrhea
Herpes
Hepatitis
Liver Disease
Syphilis
Tuberculosis
Date of AIDS-HIV diagnosis
*
MM slash DD slash YYYY
Date of Blood Transfusion
*
MM slash DD slash YYYY
Date of Chlamydia diagnosis
*
MM slash DD slash YYYY
Date of Gonorrhea diagnosis
*
MM slash DD slash YYYY
Date of Herpes diagnosis
*
MM slash DD slash YYYY
Date of Hepatitis diagnosis
*
MM slash DD slash YYYY
Date of Liver Disease diagnosis
*
MM slash DD slash YYYY
Date of Syphilis diagnosis
*
MM slash DD slash YYYY
Date of Tuberculosis diagnosis
*
MM slash DD slash YYYY
Ethnic Heritage
*
African American
Asian
Caucasian
Hispanic
Indian
Jewish
Middle Eastern
Native American
South American
Southeast Asian
Other
Other Heritage
*
Please enter other heritage
Have you had a medical diagnosis of ZIKA infection in the past 6 months?
*
Yes
No
Have you resided in, or traveled to, an area with active ZIKA transmission within the past 6 months (see link for countries)?
*
http://www.cdc.gov/zika/geo/active-countries.html
Yes
No
Have you had sex within the past 6 months with a male who is known to have either of the risk factors listed in items 1 or 2 above?
*
Yes
No
Are you in generally good health?
*
Yes
No
Please describe
*
Have you ever been told you are infertile?
*
No
Yes
Is there a history of infertility in your family?
*
No
Yes
Are you currently sexually active?
*
No
Yes
Are you taking birth control?
*
Yes
No
What is your current method of birth control?
*
If you are currently taking birth control, were your menstrual cycles regular before starting hormonal birth control?
Yes
No
Are your menstrual periods regular?
Yes
No
Do you ever skip menstrual periods? For example, has there ever been a time where you have had no period during a given month?
No
Yes
Have you ever taken Depo-Provera
*
No
Yes
Date of last shot
*
MM slash DD slash YYYY
Are you using the Mirena IUD, Skyla IUD, Depo-Provera, Implanon, or Nexplanon?
*
No
Yes
Are you currently taking any medications/treatments (including non-prescription)?
*
No
Yes
List medications and reasons for taking them
*
12. Do you currently smoke cigarettes (either regular smoker, casual smoker or occasional smoker)?
*
No
Yes
12. Please explain how often you used cigarettes in the last 6 months and the most recent date of use
*
13. Have you ever used recreational drugs (i.e. marijuana, cocaine, etc)?
*
No
Yes
13. Please explain how often you used recreational drugs in the last 6 months and the most recent date of use.
*
14. Have you ever received treatment for drug/alcohol abuse?
*
No
Yes
14. Please describe
*
15. Have any members of your immediate family ever had any issues with drug/alcohol addiction?
*
No
Yes
15. Please describe
*
16. Have any members of your immediate family ever received treatment for drug/alcohol abuse?
*
No
Yes
16. Please describe
*
17. Have you ever received treatment for depression?
*
No
Yes
17. Please describe
*
18. Have any members of your immediate family ever received treatment for depression?
*
No
Yes
18. Please describe
*
19. Have you ever been under the care of a psychiatrist?
*
No
Yes
19. Please describe
*
20. Have you ever had an eating disorder?
*
No
Yes
20. Please describe
*
21. Have you been the victim of rape and/or physical/sexual abuse?
*
No
Yes
21. Please describe
*
22. Are there any known genetic conditions or birth defects in your family?
*
No
Yes
22. Please describe
*
23. Do you have any siblings or ½ siblings with any health issues at all?
*
No
Yes
23. Please describe
*
24. Have you and/or your relatives (parents, grandparents, siblings, children) had any cancer?
*
No
Yes
24. Please describe
*
25. Have you had any hospitalizations and/or surgeries?
*
No
Yes
25. Please describe
*
26. Have you had any tattoos or body piercings within the last twelve months?
*
No
Yes
26. Please describe
*
27. Have you ever been refused as a blood donor?
*
No
Yes
27. Please describe
*
28. Have you ever lived outside of the USA?
*
No
Yes
28. Please describe
*
29. Have you ever been arrested/spent time in jail?
*
No
Yes
29. Please describe
*
30. Have you ever been clinically diagnosed with ADD or ADHD?
*
No
Yes
30. Please describe
*
31. Have you been diagnosed with Anxiety/Panic Disorder, Bipolar Disorder, or Obsessive-Compulsive Disorder?
*
No
Yes
Describe, including whether you did or do currently take medication for it:
*
Are you adopted?
*
No
Yes
Please upload a photo
Accepted file types: jpg, png, Max. file size: 8 MB.
Phone
This field is for validation purposes and should be left unchanged.