Egg Donor Pre-Screening Application

Please fill out this application form if you can answer YES to the following 5 statements.

I understand that as an egg donor I would be required to take self-administered injections for approximately 30 days.
As an egg donor, I understand that the primary requirements for application are that I be a female, between the age of 20 to 30, a non-smoker, non-drug user and that I am neither significantly overweight nor underweight for my height.
As an egg donor I understand I would be required to undergo a surgical procedure under anesthesia at the conclusion of my treatment.
As an egg donor I understand that I would be required to keep approximately 10 different doctors appointments through my treatment and that the majority of appointments will include a vaginal ultrasound and blood work.
I understand that egg donation is a very serious matter and that the intended parent or 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.
I agree to email a current photograph of myself to info@exceptionaldonors.com when I submit this application. Please include full name with photo submission.

First name:

Date of Birth:

Phone:

Email: *

Location:

Location

Height:

Weight:

Natural hair color:

Hair type:

Eye color:

Race:

Ethnicity:

Skin type:

Religious background:

Marital status:

Have you previously been a donor?:

If yes, what were the outcomes?:

If yes, how many times?:

Have you ever been pregnant? If so, what were the outcomes?:

Number of children:

If there are any genetic diseases or illnesses that run in your family please list here:

Have any members of your immediate family ever received treatment for drug and/or alcohol abuse? If so, who, when and what type?:

Have you or an immediate family member ever been treated for depression or anxiety? If yes, describe.:

Are you currently taking any medications/treatments (including non-prescription)? If yes, please list.:

Do you have any past or present medical problems?:

Allergies:

Surgeries/Hospitalizations::

Have you used recreational drugs (i.e.marijuana, cocaine, amphetamines, etc.) in the past 12 months? :

If yes, please indicate which drug and when used.:

When was your most recent pap and physical exam and were results normal?:

Do you have regular periods? If so, have you always?:

SAT Score (if applicable):

High School GPA:

Do you have any post high school education?:

Post High School GPA:

Current job/occupation:

Current job/occupation

What is your current method of birth control, if applicable?:

What day did your last menstrual period begin?:

If birth control pills, when did you start your most recent pill pack? What type are you taking?:

Have you ever received treatment for drug and/or alcohol abuse? If so when and what type of treatment (inpatient/outpatient):

Are there any known genetic diseases or conditions that run in your family?:

From 1980 throuh 1996, did you spend 3 months or more total time in the United Kingdom?:

Have you ever taken birth control pills? If so, what type? And for how long?:

How many days between the start of one period and the start of your next?:

Do you smoke?:

In the past 12 months, have you had a tattoo, ear or skin piercing?:

In the past 12 months, have you had acupuncture?:

In the past 12 months, have you had a positive test or been treated for any communicable disease?:

From 1980 through 1996, were you a member of the military, a civilian military employee or a dependent member of the US Military:

From 1980 to the present, did you receive a blood transfusion in the United Kingdom?:

From 1980 to the present, have you spent time that adds up to five years or more in Europe?:

Are you adopted? If so do you know the medical history of your biological family?:

How did you hear about us?:

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Egg Donor Pre-Screening Application