Become a Donor Form 2 - Fertility SOURCE Companies

Become a Donor Form 2

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First Name*

Last Name*

User Name*

Select a username and password:

You will use these credentials to access our database

Password*

Confirm Password*

Phone Number*

Phone Type

Email*

Are you a citizen of the United States?

If you are not a citizen, do you have legal status to work in the United States?

If you are not a citizen, describe your status. (i.e. student visa, greencard, etc)


**The Donor Source requires that you complete a W9 in order to be paid as a donor with our agency. If you are unable to complete a W9 with a taxpayer identification number (i.e. social security number), we are unable to work with you as a donor.

The Donor SOURCE works with many different clinics. Please indicate which location will be geographically acceptable to you for your doctor visits. If you are not in one of the cities listed, please select the closest location available.*

How did you find the The Donor SOURCE? Please provide as much information as possible. For example, If you found us through an advertisement indicate where. If you were referred by a clinic/doctor provide their name and city/state (for clinic/doc).*

Personal Profile


Date of Birth:

Height:

     

Weight:

Eye-Color:

Natural Hair Color:

Marital Status:

Highest Level of Education:

Have you ever been an egg donor?

Number of Egg Donor Cycles:

Which IVF clinic(s) did you work with?

Date of Retrieval




Name of Clinic




Have you ever been pregnant?*

If yes, please answer the 6 questions below:


Are you currently pregnant?

Are you currently breastfeeding?

Number of Pregnancies:

Number of Live Births:

Number of Miscarriages:

Number of Abortions:

Please indicate with a check mark whether you have had any of the following:

AIDS-HIVGonorrheaLiver DiseaseBlood TransfusionHerpesSyphilisChlamydiaHepatitisTuberculosi

If you checked any of the answers above, please indicate dates:

Race

Please check ALL that apply. You may check more than one. You will be able to enter more specific ethnic heritage below.

Ethnic Heritage/Nationality Please check ALL that apply. You may check more than one.

African AmericanAlsaceArgentineanArmenianAustrianBelgianBolivianBrazilianBulgarianCanadianChileanChineseColombianCosta RicanCreoleCroatianCzechDanishDutchEast IndianEcuadorianEgyptianEnglishEthiopianFilipinoFinnishFrenchFrench-CanadianGermanGreekGuatemalanHonduranHungarianIcelandicIranianIrishIsraeliItalianJamaicanJapaneseJewishKoreanLebaneseMexicanMoroccanNative AmericanNicaraguanNorwegianPacific IslanderPakistaniPalestinianPanamanianParaguayanPersianPolishPortuguesePuerto RicanRomanianRussianScandinavianScottishSlavicSlovakianSouth AfricanSpanishSwedishSwissTaiwaneseThaiTurkishUkranianUraguayanVenezuelanVietnameseWelshYugoslavianZairian

Other:

General Questions


Are you in generally good health?*

Have you ever been told you are infertile?*

Is there a history of infertility in your family?*

Are you currently sexually active?*

Are you currently taking birth control?*

If you are currently taking birth control, were you menstrual cycles regular before starting hormonal birth control?

Are your menstrual periods regular?

Do you ever skip menstrual periods? For example, has there ever been a time where you have had no period during a given month?

Have you ever taken Depo-Provera?*

Are you currently using the Mirena IUD, Skyla IUD, Depo-Provera, Implanon, or Nexplanon?*

Are you currently taking any medications/treatments (including non-prescription)?*

Do you currently smoke cigarettes (either regular smoker, casual smoker or occasional smoker)?*

Have you ever used recreational drugs (i.e. marijuana, cocaine, etc)?*

Have you ever received treatment for drug/alcohol abuse?*

Have any members of your immediate family ever had any issues with drug/alcohol addiction?*

Have any members of your immediate family ever received treatment for drug/alcohol abuse?*

Have you ever received treatment for depression?*

Have any members of your immediate family ever received treatment for depression?*

Have you ever been under the care of a psychiatrist?*

Have you ever had an eating disorder?*

Have you been the victim of rape and/or physical/sexual abuse?*

Are there any known genetic conditions or birth defects in your family?*

Do you have any siblings or ½ siblings with any health issues at all?*

Have you and/or your relatives (parents, grandparents, siblings, children) had any cancer?*

Have you had any hospitalizations and/or surgeries?*

Have you had any tattoos or body piercings within the last twelve months?*

Have you ever been refused as a blood donor?*

Have you ever lived outside of the USA?*

Have you ever been arrested/spent time in jail?*

Have you ever been clinically diagnosed with ADD or ADHD?*

Have you been diagnosed with Anxiety/Panic Disorder, Bipolar Disorder, or Obsessive-Compulsive Disorder?*

Are you adopted?*

Signature


I enter my full name and today’s date in the fields below as a verification of the information I have provided above.
I certify that all information provided is honest and factual.

Print Name

Date


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