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Egg Donor Application
Begin Application
Take the first step towards giving an incredible gift!
Name
*
First
Middle
Last
Maiden Name
Email
*
Enter Email
Confirm Email
Are you between the ages of 20 – 28?
*
Yes
No
Is your BMI below 30?
*
You can use this
BMI calculator
Yes
No
Do you smoke or use tobacco in any form?
*
Yes
No
Are you currently taking any anti-depressants or anxiety medications?
*
Yes
No
Have you ever been diagnosed with ADD/ADHD or any other type of learning disability?
*
Yes
No
Have you ever tested positive for the HIV virus, HTLV infection, Hepatitis B virus or Hepatitis C virus?
*
Yes
No
In the past 12 months have you undergone tattooing, ear piercing or body piercing?
*
Yes
No
In the past 12 months have you been treated for or had Syphilis, Chlamydia, or Gonorrhea?
*
Yes
No
Have you traveled outside of the US in the past 12 months?
*
Yes
No
Have you ever been or applied to be an egg donor before?
Yes, I've applied, was accepted and donated before
Yes, I've applied, was accepted but never donated
Yes, I've applied but was denied
No, I've never applied before
Do you have any children?
*
Yes
No
How many times have you donated before?
1 time
2 times
3 times
4 times
5 times
More than 5 times
Have you applied or been screened to be an egg donor with other agencies?
Yes
No
Which clinic(s) and location(s)?
*
Can you obtain accurate, up-to-date health information on your biological parents, grandparents and siblings?
*
Yes
No
How did you hear about us?
*
Craigslist
Google
Facebook
Friend
Magazine
Who did you get referred by?
*
What magazine?
*
Your Personal Details
Name
*
First
Middle
Last
Maiden Name
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of birth
*
MM slash DD slash YYYY
Cell Phone Number:
*
Home Phone Number:
Work Phone Number:
Who is your emergency contact?
*
Please provide a contact who is not living with you.
First
Last
Home or Cell Phone Number:
*
Health Insurance Carrier:
Your Family & Living Situation
What is your marital status?
*
Married
Engaged
Relationship (co-habitating)
Relationship (living separately)
Single
Divorced (finalized)
Divorced (in process)
Legally Separated
Separated (non-legal)
Widowed
What is your spouse/partner's name?
*
First
Middle
Last
What's your spouse/partner's date of birth?
*
MM slash DD slash YYYY
Spouse/Partner's Driver’s License Number:
Issuing State:
Will you have emotional support from someone close to you?
*
Yes
No
What relationship is this person to you?
*
Does this person live with you?
*
Yes
No
With whom have you discussed your intentions about becoming an egg donor and what was their reaction?
*
Did you consult with your family when completing your Family Medical history?
*
Yes
No
Your Characteristics
What is your height?
*
What is your weight?
*
What is your blood type?
*
A+
A-
B+
B-
AB+
AB-
O+
O-
I don't know
What is your Body Mass Index (BMI)?
*
You can use this
BMI calculator
What is your race?
*
What is your ethnic background?
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latina
Native Hawaiian or Other Pacific Islander
White
Ethnicity father:
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Ethnicity mother:
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latina
Native Hawaiian or Other Pacific Islander
White
Ethnicity maternal grandfather:
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Ethnicity grandfather:
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Ethnicity maternal grandmother:
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latina
Native Hawaiian or Other Pacific Islander
White
Ethnicity grandmother:
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latina
Native Hawaiian or Other Pacific Islander
White
Are you religiously affiliated?
*
Yes
No
What is your current religious affiliation?
*
Physical build:
*
Petite
Small
Medium
Large
Eye color:
*
Natural hair color:
*
Current hair color:
*
Natural hair texture:
*
Hair thickness:
*
Complexion:
*
Very fair
Fair
Tan
Light olive
Olive
Dark Olive
Brown
Black
Dominate hand:
*
Right-handed
Left-handed
Ambidextrous
Dimples:
*
Yes
No
Are you adopted?
*
Yes
No
Do you know your medical history?
*
Yes
No
Please provide a description for each parent and grandparent:
*
Mother, Father, Grandmother (mom's side), Grandmother (dad's side), Grandfather (mom's side), Grandfather (dad's side)
Relative
Race
Height
Weight
Physical build
Do you smoke?
*
Yes
No
Have you ever smoked?
*
Yes
No
Do you drink alcohol?
*
Yes
No
How often?
*
Have you used illegal drugs?
*
Yes
No
Would you agree to take a drug test?
*
Yes
No
Tattoos & Piercings (month & year):
Describe any special talents, skills or abilities that you have (artistic, athletic, intellectual, other):
*
What size pants do you wear?
*
Size tops?
*
Shoe size
*
Bra size:
*
Dress size:
*
What is your favorite clothing?
*
Describe how you look:
*
How athletic are you?
*
Not athletic
Average
Very
What types of exercises or physical activities do you do?
*
What do you like doing in your spare time?
*
What do you like most about yourself?
*
If you could change one thing in the world what would it be and why?
*
What is important and what do you value most in life?
*
Employment & Education
Current occupation:
*
Hours:
Full time
Part time
Typical weekly work schedule – days and times:
Year completed High School:
Grade average:
Received GED:
Currently in college, pursuing degree in:
GPA:
Completed college, degree in:
GPA:
Name of Colleges attended or attending:
Attending Technical or Business School?
*
Yes
No
Completed Technical or Business School program?
*
Yes
No
Title of Degree and Year received
*
Academic Strengths (i.e. math, reading):
Musical Talent or Instrument?
Artistic Talent?
Do you speak a language other than English?
*
Yes
No
What languages?
*
Athletic/Sport Skills?
Your Health History
Age at first period:
*
Are your periods regular?
*
Yes
No
Any treatments needed for menstrual problems?
*
Yes
No
Please describe:
*
Have you ever had trouble becoming pregnant?
*
Yes
No
Number of sex partners within the last 6 months:
*
Has your sex partner had other sex partners in the last 6 months?
*
Yes
No
Not applicable
Have you ever had an HIV screening completed?
*
Yes
No
Please give results and year:
*
Have you had any history of abnormal PAP Smears?
*
Yes
No
Please give results and date last pap smear completed:
*
Are you using birth control?
*
Yes
No
What form(s) of birth control are you currently using?
*
Birth Control Pills
NuvaRing
Diaphram
Patch
Implanon/Nexplanon
Tubal Ligation
Partner Vasectomy
Condoms
IUD
Essure
Depo Shot
How long have you used this form of birth control?
*
Your Pregnancy History
What was the date of your last successful pregnancy?
Month
Day
Year
Pregnancies:
Year
C-Section/Vaginal
Miscarriage
Termination
Other
Healthy baby
Did you have any complications during these pregnancies?
Yes
No
Please describe:
*
Children:
Boy/Girl
DOB
Sex
Age
Child lives with?
I do not have any children
Were the children healthy at birth?
Yes
No
Please describe:
Have you had any surgery or medical procedure?
*
Yes
No
Please list the year and treatment:
*
Year
Treatment
Have you ever been in counseling or psychotherapy?
*
Yes
No
Please describe:
*
Your Family Genetic History
Predominant family hair color:
*
Predominant family eye color:
*
Predominant family stature:
*
Short
Average
Tall
Predominant size:
*
Petite/Small
Average
Large
X-large
Predominant family trait (physical)
*
Ex: tall, big eyes
Family personality traits:
*
Family traits for sports:
*
Family traits for music:
*
Family traits for education/school:
*
Family intellectual traits:
*
Family traits for technical/manual skills:
*
Have twins or multiple births occurred in your family?
*
Yes
No
How would you rate the longevity of age in your family?
*
Are there any traits that are common in your family?
*
Is there anything that is very typical in your family?
*
Please provide a photo of yourself:
This should include at least one headshot and one full body picture.
Drop files here or
Select files
Max. file size: 30 MB, Max. files: 10.
If there's anything you would like to add to your application, feel free to do so here:
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Home
Future Parents
Getting Started
LGBTQ+ Parenting
California Surrogacy Laws
Surrogates
Surrogate Inquiry
Surrogate Application
Surrogate FAQs
Surrogate Requirements
Surrogate Compensation
Surrogate Mother Process
Wellness Program
Surrogate Referral Program
Payment Request
Donors
Egg Donor Application
Egg Donor Requirements
Egg Donor Compensation
Egg Donation Process
About
Our Professional Network
Blog
Contact
PHONE: +1 (619) 271-4093
