You’ve taken the first step! Help bring hope of a child to a loving family.
Date of Birth
What are the best times to reach you?
I understand that as an egg donor, I would be required to take self-administered injections for approximately 20 days.
As an egg donor, I understand that the primary requirements for application are that I be a female, between the age of 21-29*, a non-smoker, non-drug user and that I am neither significantly overweight nor underweight for my height, and that I have some formal education beyond high school.
As an egg donor, I understand that I must have two ovaries.
As an egg donor, I would be required to undergo a procedure under sedation to remove my eggs from my ovaries at the conclusion of my treatment.
As an egg donor, I understand that I would be required to keep approximately 10 different doctors appointments throughout my treatment, many of which are between the morning hours of 8am and 10am.
I understand that egg donation is a very serious matter, and that the intended 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.
Please choose a username and password
Your username and password must contain at least 8 characters and at least one number or symbol
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 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).
Natural Hair Color
Level of Education
Have you ever been an egg donor?
# of Egg Donor Cycles
Which IVF clinic(s) did you work with?
Have you ever been pregnant?
If yes, please answer the 6 questions below.
Are you currently pregnant?
Are you currently breast-feeding?
# of Pregnancies
# of Live Births
# of Miscarriages
# of Abortions
Please indicate with a check mark whether you have had any of the following:
If you checked any of the answers above, please indicate dates:
Race. Please select ALL that apply:
Ethnic Heritage / Nationality:
Please select ALL that apply.
You may check more than one.
Are you in generally good health?
If No, describe below:
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 yes, what is your current method of 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?
If Yes, enter date of last shot below:
Are you currently using the Mirena IUD, Skyla IUD, Depo-Provera, Implanon, or Nexplanon?
Are you currently taking any medications/treatments (including non-prescription)?
If Yes, list medications and reasons for taking them below:
Do you currently use nicotine including smoking cigarettes/use e-cigarettes? (please mark yes for regular, casual, or occasional use).
If yes, please explain how often in the last 6 months and the most recent date of use.
Have you ever used recreational drugs (i.e. marijuana, cocaine, etc)?
If yes, please explain how often you used recreational drugs in the last 6 months and the most recent date of use.
*Please note that you will be drug tested at your medical evaluation.
Have you ever received treatment for drug/alcohol abuse?
If Yes, describe below:
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?
Please think about your immediate family members, nieces, nephews, aunts, uncles, and first cousins.
Do you have any siblings or ½ siblings with any health issues at all?
If so, please give us details as to the health issue
Have you and/or your relatives (parents, grandparents, siblings, children) had any cancer?
If Yes, describe below including the relative, type of cancer and age of onset:
Have you had any hospitalizations and/or surgeries?
If Yes, describe below with the year each occurred:
Have you had any tattoos or body piercings within the last twelve months?
If Yes, please indicate the date and whether it was a tattoo or piercing:
Have you ever been refused as a blood donor?
If Yes, please list date(s) and reason(s):
Have you ever lived outside of the USA?
If Yes, please list date(s) and country(ies):
Have you ever been arrested/spent time in jail?
If Yes, please list date(s) and explanation:
Have you ever been clinically diagnosed with ADD or ADHD?
If so, did you or do you currently take medication for it?
Have you been diagnosed with Anxiety/Panic Disorder, Bipolar Disorder, or Obsessive-Compulsive Disorder?
If so, describe below including whether you did or do currently take medication for it?
Are you adopted?
If yes, will you be able to able to obtain medical information from your biological parents and one set of biological grandparents?
(Note that this is required by the physicians we work with)
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.