EggDonorCorner.com - Donor Application

Donor Application

Thank you for your interest in our Egg Donor Program. The generosity of young women today allows for the creation of families that have only been a dream for many thus far. An Egg Donor's destiny is allowing another person's journey to begin. We look forward to being a part of your destiny. Please rest assured that all information provided is strictly confidential and protected.

First Name *
Last Name *
Address *
City *
State *
Zip/Postal Code *
Country
Email Address *
Willing to Travel? *YESNO
How did your hear about us? *
Main Phone Number *
OK to leave message? *YESNO
Second Phone Number *
OK to leave message? *YESNO
Best time to reach you? *
Date of Birth *
Blood Type *
Height *
Weight *
Eyes *
Natural Hair Color *
Skin *
Ethnic Background * Ethnic background (German, French, Chinese, etc)
Race * Race (Caucasian, African American, Asian, etc)
Do you have any Native American blood ancestry? If yes, how much? *
Are you a U.S. citizen or permanent resident? *YESNO
Degree *
major *
Occupation *
Health Insurance *
Were you adopted? *YESNO
How much do you smoke? *
Drink? *YESNO
Use drugs? *YESNO
Marital Status? *MARRIEDSINGLE
If single, are you in steady relationship? *YESNO
Are you sexually active? *YESNO
If YES, number of sex partners last year: *
Number of sex partner(s) in lifetime: *
Number of pregnancies: *
Number of children: *
Any medical problem? *YESNO
If YES, please describe: *
Do you or any members of your family suffer from any serious illness? *YESNO
If so, what and who? *
Do you or any members of your family suffer from depression, or any other chronic mental illness? *YESNO
If so, what and who? *
Ever had surgery? *YESNO
If YES, please describe: *
Any tattoos or body piercing? *YESNO
If YES, where on on body and date received *
Would you be willing to donate for a single woman, a single man, or a gay couple? (a negative answer will not disqualify you from being selected as a donor.) *YESNO
Have you ever donated for another egg donation agency? What was the outcome? *
Are you currently registered with any other egg donation agencies? *YESNO
What type of contraceptives do you presently use? ( If pills, please specify which kind you are taking.) *
When was your last Pap Smear? *
What were the results? *
Have you ever had an abnormal Pap Smear? If so, what was the outcome? *
Have you ever had a sexually transmitted disease? If so, what was it and what was the outcome? *
Have you ever considered surrogacy and would you like to receive more information? *YESNO
Have you ever used any kind of mind-altering drugs such as marijuana, LSD, heroin, or cocaine? *YESNO
If YES, please state details and last date used: *
Have you ever been incarcerated? *
Have you ever used an injected drug or had a sexual partner who did? *
Have you ever engaged in prostitution? *YESNO
Have you been sexually active with an HIV-positive person? *NOYES
Have you been sexually active during the past six months? *NOYES
Are you currently sexually active? Do you have more than one partner? *
Are you currently in a monogamous relationship? *YESNO
Have you ever had a gay or bisexual partner? *
Have you, or a partner of yours, ever had a sexually transmitted disease (gonorrhea, syphilis, hepatitis, chlamydia, herpes, condyloma, or trichomoniasis)? If so, please describe the diagnosis, year, and treatment: *
Have you ever been refused as a blood donor? *
If so, why? *
I agree that I represent that all written representations and information provided and/or to be provided to any professional, physician, physician's assistant, nurse, attorney, are true, correct and complete. *I AGREE

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