Egg Donor Application
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- Alyson Audra Campbell
- 5 years ago
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1 Egg Donor Application First Name: Last Name: Current Street Address: What City/County/State are you in? Contact Phone Number: address: DOB: Height: Weight: Natural Hair Color and texture: Eye Color: Are you a US citizen? If not where are you from and how long have you lived in the USA? Do you have any previous egg donor experience? What is your Ethnicity? (please list all genetic background that you are aware of and race affiliations) Are you of any Asian decent? Are you of any Jewish decent? What is your complexion and tanning ability? Describe your physical build: (sm, med, lg, petite, curvy, tall, short, slender, full ect ) Describe your personality and traits: (creative, intelligent, quiet, enthusiastic ect )
2 What level of egg donation would you like to have with Intended Parents? An Open one where you could meet/speak with them and exchange future contact information, Semi- Open where you would meet or speak with them but with no future contact, completely anonymous, or something else? Are you willing and comfortable donating to same sex partners and/or single parents? Would you be willing to travel to donate eggs if you were reimbursed for travel expenses? Have you ever lived abroad for more than 6 months? If so where, when, and for how long? Do you or have you ever used any form of tobacco? If you have quit how long ago? Do you drink any alcoholic beverages? If so how many/often? Have you ever used Marijuana or other illegal drugs? (SLS preforms drug tests on all egg donors as required with California law and if a positive result is found the applicant will be banned from egg donation in the state and will be liable for screening fees) Left or Right Handed? Have you or any of your immediate biological relatives (family related by blood e.g. Parents, grandparents, siblings) had any of the following: (please list who if answering yes) Ovarian Cancer Migraine Headaches Asthma Eye Disease/Retinal Blastoma Emphysema Nervous System Problems Thyroid Issues High Blood Pressure Chronic Bronchitis Paralysis Liver Disease
3 Learning Disability Diabetes Speech problems Kidney Problems Cystic Fibrosis Manic Depression Dwarfism Psychological Imbalance Colitis Tumors Arthritis ADHD Muscular Dystrophy Cerebral Palsy Spina Bifida Skin Disorders Leukemia AIDS Sickle Cell Anemia Anemia Hemophilia Epilepsy/Convulsions Mental Illness Heart Disease Schizophrenia
4 Lung Disease Autism Ulcers Obesity Cancer (type?) Tuberculosis Deafness from childhood or birth Cataracts/Glaucoma Blindness Cross Eyed Glasses or Contacts Color Blind Tay Sachs Hear Attach (age?) Alzheimer s Hepatitis (type?) Fibroids Multiple Sclerosis Down s Syndrome Heart Murmur Stroke (age?) Any Birth defects or deformities (describe) Highest level of education: Type of employment or student status:
5 Will you take an IQ test if asked? Or if you have taken one in the past year what was your score? Do you have a regular cycle every month and how many days between cycles? How long does it last? Is it heavy and/or do you have strong cramping? What age did you star your period? Are you on birth control, if so what kind? How long have you been using this form of birth control? Have you ever had any form of STD? Please list along with treatment and date cleared if applicable: Date of your last PAP smear and OBGYN checkup? Any irregular PAP smear results? If so explain. Have you had a tubular ligation (tubes tied)? Have you had any still births, miscarriages, or premature births? If so please list: Have you had a cesarean section? Have you had any fertility treatment, medical treatment or help conceiving? Do you understand and agree that photos of yourself will be required and provided by you to be shown to potential Intended Parents but will not be used for any other purposes? Do you understand and agree that once you have been selected as an egg donor that the recipients of your eggs or embryos created with your eggs, have full decision making capability on how the embryos are used. This may include storage; further donation to another third party, stem cell research or destroying them?
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