Donor Mother Donor Mothers date of birth (this information may be needed if additional medical screens are required for FDA Donor eligibility)

Transcription

1 Donor Mother Donor Mothers date of birth (this information may be needed if additional medical screens are required for FDA Donor eligibility) 1975 Donor Mothers Donor Mothers Phone Number May we leave a voic at this phone number? Preferred method of contact? Best time to reach you? Donor Father either anytime Donor Fathers Donor Fathers date of birth (this information may be needed if additional medical screens are required for FDA Donor eligibility) 1973 Donor Fathers Phone Number May we leave a voic at this phone number? Preferred method of contact? Best time to reach you? Address How did you hear about us? Marital Status Length of marriage or domestic partnership: Donor Mothers current career or occupation: Donor Mothers hobbies and interests mornings Paonia, CO Our clinic Married (ceremonial) 13 years Currently a full time parent, on hiatus from being a school counselor and child, adolescent and family therapist Hiking, cycling, cross country skiing, walking the dogs, gardening, reading, being outdoors in nature, travel, languages, kayaking, cooking

2 Donor Fathers current career or occupation: Donor Fathers hobbies and interests Mechanical and civil engineer, working in bicycle design and manufacturing as well as solar design Mountain biking, telemark skiing, skijoring with our dogs, hiking and camping with our daughter, brewing beer and mead, growing fruit, wood-fired baking, cooking and eating spicy foods, playing guitar, flyfishing, making things energy efficient How many embryos are currently in storage? 6 Do you have any information about the embryos? (ie. Quality, or embryo day) * Where are the embryos currently stored? * What year were the embryos stored? * 2015 Did you use an egg donor? What information do you have about the egg donor (i.e. was she known or anonymous)? Age at time of retrieval 25 Biological Mother Ethnicity Biological Mother Natural Hair Color: Biological Mother Eye Color Biological Mothers Height if known: Biological Mothers Weight if known: Biological Mothers Heritage Group/s if known (Irish, German, Japanese, etc): Biological Mothers Skin Tone if known Biological Mothers Education Level: Egg Donors Career or occupation if known (please do not list specific places of employment. Use general terms): Egg Donors Hobbies/Interests Biological Mother known medical conditions: Biological Mother known Allergies : blastocyst stage, frozen individually, vitrification process University of Colorado IVF Lab Anonymous donor through Angel's Gift. Donor profile on record. Caucasian Dark Blonde Green 5'4" 120 lbs. Irish, Portuguese, English, German Light Tan Some College works as a bartender while studying biology and to become a personal trainer rock climbing, snowboarding, hiking, fitness, spending time outside with her dog See donor profile See donor profile

3 Did you use a sperm donor? What information do you have about the sperm donor (i.e. was he known or anonymous)? Age at time of retrieval 41 Biological Father Ethnicity Biological Father natural hair color Biological Father Eye Color No n/a Caucasian Dark Blonde Hazel Biological Fathers Height if known: 6' 4" Biological Fathers Weight if known: Biological Fathers Heritage Group/s if known (Irish, German, Japanese, etc): Biological Fathers Skin Tone if known Biological Fathers Education Level: Sperm Donors Career or occupation if known (please do not list specific places of employment. Use general terms): Sperm Donors Hobbies/Interests Biological Father known medical conditions: Biological Father known Allergies Number children born from these embryos (genetic siblings), and genders Do you have any other children (from previous marriages, or children not born from these embryos) Would you be willing to share photos of your children (the genetic siblings of the embryos) 190 lbs German, Czech Fair Masters n/a n/a None Dust mites, mold, hops, shellfish One daughter No

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5 Share a short description about your current children (i.e. personality, temperament, intelligence, etc) Describe the type of family you would like your embryos to go to: Preferred marital status or age (if any): What type of contact do you imagine having with Our daughter is currently four months old and a complete joy! She is bright, alert and very curious. She delights in going for walks, smelling flowers, petting her dogs and exploring her surroundings. She is generally an easygoing, social and happy baby. She is ahead on all milestones thus far. Currently, she likes to smile, laugh, coo, babble, squeal, roll over, shake her rattle, kick her feet, reach for things, put things in her mouth, drool, do push ups, swing, listen to stories, dance to music, nurse and cuddle. Any family that has not been able to experience the joy of having a child via other means. We would like to give first preference to couples without children No preference. Our desire would be to have contact of

6 your recipient couple? some sort. In general, we are flexible, but this would be our ideal preference. We would not want either family to feel obligated to pursue regular, involved contact. Instead, we're imagining something along the lines of a distant cousin... our daughter would know this genetic sibling exists and should she become curious, she can make contact when appropriate. Perhaps we send holiday cards once per year just to see how the children resemble one another? It would be new territory for us, so we want to keep an open mind and open heart. We foresee a possibility that this relationship could be important for our daughter as she ages and navigates how her conception and birth story figure into her identity. Will you plan to tell your existing children about the embryo donation? If so, do you want the genetic siblings to have access to each other? Would you want to know if the donation resulted in a pregnancy and birth? Are you willing to donate to a single parent? Are you willing to donate to a gay couple? Will you want a background check on the Embryo Recipients? Fees for any Criminal background checks will be the responsibility of the Embryo Recipients and usually cost approximately $25.00 per person. Do you have a preference on the recipient couples religion? and yes, at least via the donor sibling registry Not sure at this time No What message would you like passed on to your recipient couple? AGENCY NOTES: Congratulations and good luck! What a long journey it has been... we hope you're almost there. Egg Donor was later discovered to be an intermediate carrier for Fragile X - Genetic report on file with Agency. CGG repeats observed: 31,53