Become an Egg Donor Step 2 - complete

Full Legal Name

Date of Birth

Age

Email*

Mobile Phone Number

Citizenship

City

State

Emergency Contact (Name & Relationship)

Emergency Contact Phone Number

Section B: Physical Characteristics

Blood Type (if known)

Eye Color

Hair Color

Skin Complexion

Natural Hair Texture

Dominant Hand

Section C: Education & Employment

Highest Level of Education Completed

Field of Study / Major

College or University Attended

Current Occupation

Employer (optional)

Languages Spoken

English Spanish Other

Higher education experiences and accomplishments

Section D: Reproductive History

Age at First Menstrual Period

Average Cycle Length (days)

Are cycles regular?

Yes No

Date of Last Menstrual Period

History of Hormonal Birth Control Use

History of Fertility Treatment

History of Ovarian Surgery or Diagnosis (PCOS, endometriosis, cysts)

Yes No

If yes, please explain

History of Pregnancy

Yes No

If yes, outcomes (live birth, miscarriage, termination)

Prior Egg Donation Cycles

Yes No

Number of cycles and year(s); any complications

Section E: Medical History (Donor)

Current Medications or Supplements

Allergies (medication, food, environmental)

Surgical History (procedure & year)

Section F: Mental Health & Psychosocial History (ASRM Required)

Mental health history does not automatically disqualify donors. Information is reviewed confidentially by licensed professionals.

Diagnosed with or treated for anxiety, depression, ADHD, bipolar disorder, or other mental health conditions?

Yes No

Ever hospitalized for mental health reasons?

Yes No

Ever had suicidal thoughts or attempts?

Yes No

Currently in therapy or counseling?

Yes No

Current stress level

Low Moderate High

Section G: Lifestyle & Risk Assessment (FDA Focused)

Tobacco or Nicotine Use (current or past)

Alcohol Use

None Social Moderate Heavy

Recreational Drug Use (past or present)

History of intravenous drug use

Yes No

History of incarceration longer than 72 hours

Yes No

Tattoos or piercings in the past 12 months

Yes No

International travel in the past 12 months (countries & dates)

Section H: Talents, Accomplishments, Physical Lifestyle

This section helps intended parents learn more about you as an individual beyond medical history.

Talents & Skills (talent, years of experience, level)

Academic, Professional & Personal Accomplishments

Do you engage in regular physical activity?

Yes No

If yes, describe

Organized sports or athletic training in the past?

Yes No

If yes, describe level and duration

Additional Information (optional)

Donor Acknowledgment

I understand that the information provided in this section may be shared with intended parents in a non-identifying manner.

Section I: Genetic & Family History Intake

This section is incorporated by reference and must be completed in full.

Father

Mother

Father's Father

Father's Mother

Mother's Father

Mother's Mother

Section J: Donor Preferences & Disclosure

Donation Type Preference

Anonymous Semi-open Open (future contact possible) Other

Willingness to travel for donation

Yes No Possibly

Willingness to donate more than once

Yes No

Willingness to be matched with

Single parents Same-sex couples International intended parents

Section K: Legal Acknowledgments & Consent

I understand I will undergo medical, psychological, and genetic screening. I understand I will be required to complete FDA infectious disease testing. I understand I will be represented by independent legal counsel. I understand I may withdraw from the process prior to medical stimulation.

I acknowledge and agree to the above statements

Final Attestation

I certify that all information provided in this Egg Donor Intake & Screening Packet is true, complete, and accurate to the best of my knowledge. I understand that omission or misrepresentation may result in disqualification.

Date

Thank You — Let's Complete Your Application

This is Step 2 of your application. A few details are repeated below to confirm your record, followed by the full health and background profile our medical team needs to review your candidacy. Your privacy is always protected — overseen by Dr. Kyle Kramer (Former FDA Consultant).

Section B: Physical Characteristics

Section C: Education & Employment

Section D: Reproductive History

Section E: Medical History (Donor)

Section F: Mental Health & Psychosocial History (ASRM Required)

Section G: Lifestyle & Risk Assessment (FDA Focused)

Section H: Talents, Accomplishments, Physical Lifestyle

Section I: Genetic & Family History Intake

Section J: Donor Preferences & Disclosure

Section K: Legal Acknowledgments & Consent

Final Attestation