Egg Donor Application

Take the first step towards giving an incredible gift

Name*
First Middle Last Maiden Name
Email*
Enter Email Confirm Email
What City & State do you reside?*
City State
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
Can you obtain accurate, up-to-date health information on your biological parents, grandparents and siblings?*
- 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
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)?*
How did you hear about us?*
- Craigslist
- Google
- Facebook
- Friend
- Magazine
- EggDonorAgency.net
Who did you get referred by?*
What magazine?*
Your Personal Details
Name*
First Middle Last Maiden Name
Address*
Street Address Address Line 2 City State ZIP Code
Date of birth*
Date Format: 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?*
Date Format: 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?*
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
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?
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:*
Are there twins in your family?*
- Yes
- No
Which side of the family & generation?*
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 you:
This should include at least one headshot and one full body picture.
Drop files here or
If there's anything you would like to add to your application, feel free to do so here: