Egg Donor Application

To become a egg donor, we need to learn some information about your personal and medical history. Your responses to these questions will help us to make sure that your health and medical history are compatible with the donation process and in particular for egg donors that it will not involve any increased risks for you. This effort will also help us to match you to an appropriate recipient.

Please provide complete and accurate information to these questions. If you do not know the answer, ask a parent or family member. Any information you provide during the donation process, will remain completely confidential. Some of the information from this questionnaire will be given to the recipient(s) as noted but all identifying information is removed.
 

Non-Eligible Criteria – FDA Requirements

  • Persons who spent 3 months or more cumulatively in the United Kingdom from 1980 through the end of 1996.
  • Persons who are current or former US Military members or civilian military or dependents of a military member or civilian employee who resided at US military bases in Northern Europe (Germany, Belgium and the Netherlands) for 6 months or more cumulatively from 1980 through 1990 or elsewhere in Europe (Greece, Turkey, Spain, Portugal and Italy) for 6 months or more cumulatively from 1980 through 1996.
  • Persons who spent 5 years or more cumulatively in Europe from 1980 until present (including time spent in the UK from 1980 through 1996).
  • Persons who received any transfusion of blood or blood components in the UK or France between 1980 through present.
  • Persons or their sexual partners who were born in certain countries in Africa (Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria) after 1977. Or, persons who have received a blood transfusion or any medical treatment that involved blood in the countries listed in this paragraph.

Please contact us prior to filling out the application if:

  • You been diagnosed with West Nile Virus in the past year.
  • You been diagnosed with Syphilis in the past year.
  • You been diagnosed with Chlamydia in the past year.
  • You been diagnosed with Gonorrhea in the past year.
  • You had a tattoo or body piercing in the past year.
  • You had the smallpox vaccination within the past 8 weeks.

Please contact us prior to filling out the application if you have spent any time in the following countries since 1982:

  • Albania
  • Austria
  • Belgium
  • Bosnia-Herzegovina
  • Bulgaria
  • Croatia
  • Czech Republic
  • Denmark
  • Finland
  • France
  • Germany
  • Greece
  • Hungary
  • Ireland
  • Italy
  • Liechtenstein
  • Luxembourg
  • Macedonia
  • Netherlands
  • Poland
  • Portugal
  • Romania
  • Slovak Republic
  • Slovenia
  • Spain
  • Sweden
  • Switzerland
  • United Kingdom – includes the following: England, Northern Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar, and the Falkland Islands.
  • Yugoslavia

• Donor Application Form 1

Identification

If you are not a US Citizen or permanent resident, we are unable to process your application.
If you are adopted, we are unable to process your application.

Demographics

Address
Address Line 1
Address Line 2
City
State/Province
Zip/Postal
Country
Enter Email
Confirm Email

Medical Insurance

Donation History

Consultation