Egg donor information form and agreement

Jewish Embryo Bank

10913 Parkside Drive NW

Suite 304

Knoxville, Tennessee 37934

Phone: 865-970-1757

Egg Donor Information

The wonderful opportunity to provide another family with the gift of having their own child is considered to be an amazing and rewarding thing. We are making it easier for an infertile couple or single woman to be able to carry and give birth to a child. By providing healthy embryos we also save the intended parents the tremendous efforts and expense involved in IVF. The financial and emotional burden can be eased by spreading the costs between more than one family. We do require that our donors possess a strong sense of commitment, the ability to demonstrate integrity and dependability, as well as a genuine humanitarian desire to assist an infertile couple/individual in conceiving. Egg donation requires a serious contribution of time and effort and involves undergoing medical procedures. Our donors must be willing to commit to the entire process, from start to finish. Egg donation has been described as one of the most powerful and rewarding decisions a woman can make. We are here to help make the process a pleasant and fulfilling experience.

Our agency matches intended parents with donors and manages all the complex arrangements associated with an egg donation cycle as well as IVF. We are helping families conceive children that they are unable to conceive on their own due to a wide variety of reasons. Our organization has medical, legal and other staff located in Los Angeles, California; Knoxville, Tennessee and Rockville, Maryland.

Donor Criteria

Donors must be between the ages of 18 and 30 in good health.

History of smoking will be reviewed. Urine toxicology tests will be completed during the screening process to confirm abstinence.

Donors are responsible for updating their profile/application annually.

Donors’ Body Mass Index must be between 18 and 29 because overweight Donors’ health and egg quality may be at placed risk when taking medications necessary for an egg donation cycle. Please visit the Centers for Disease Control’s website to determine your BMI at http://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm

Donors cannot have obtained any tattoos, body piercing or blood transfusions within the past 12 months prior to initiating an egg donation.

The Matching Process

The following steps describe the typical egg donation process:

The donor submits an application/profile.

We review the application to ensure that the donor meets our criteria and, if the donor is accepted and we are able to produce viable embryos, she is included in our online donor database.

The donor can decide what level of contact with intended parents, if any, she feels comfortable with.

The donor and embryo bank will then sign an egg donation contract with one another (each party will be represented by an independent lawyer). This contract will address all the legal implications of the egg donation agreement, including the legal responsibility of both parties, compensation agreement terms, ownership of eggs resulting from the donation, etc.

Once the contract has been signed, the donor will then be medically and psychologically screened. The embryo bank will determine exactly what type of screening the donor must undergo.

If the Donor successfully passes all of her psychological and medical screening, the actual egg donation cycle begins.

Donation Cycle

1.

Once the matching process is complete, all medical and psychological screening must be completed before the egg donation cycle begins. The donor’s screening is completed as required and may include the following:

Medical Screening: Generally consists of a series of blood tests, cervical cultures, a physical exam, and a vaginal ultrasound. This screening is carried out to confirm that the donor is medically healthy and able to donate. Additionally, a blood test is usually required on the third day of the donor’s menses to assess hormonal levels.

Genetic Screening: Generally in the form of blood tests; investigates whether the donor is a carrier of genetics diseases, such as Cystic Fibrosis.

Psychological Screening: Conducted by a psychologist or social worker to ensure that the donor is aware of all the psychological implications of the egg donation process. This screening will also help determine whether the donor is psychologically sound enough to be a donor.

Partner Screening: If the Donor has a sexual partner, s/he may also be required to undergo blood tests to screen for sexually transmitted diseases.

The donor will be put on birth control pills to help regulate her menstrual cycle.

If a "Lupron Cycle" is used, at (approximately) the end of the third week of her cycle, the donor will begin taking Lupron (daily self-administered injections) to stop her ovaries from ovulating. Prior to beginning Lupron, the donor may be monitored via a blood test and vaginal ultrasound to confirm that she is ready to administer these injections. If an "Antigon Cycle" is used, the donor will not take Lupron, but will begin with Step 5 (see below).

The Donor can expect to receive a portion of her compensation, in the amount of $500, when she begins her Lupron or Antigon injections.

After taking Lupron for 7-14 days, the donor will then begin taking stimulation medication (self-administered injections), which will cause her egg follicles to grow. This medication is generally taken for 8-11 days. Though these medications come in many different brand names, Fertinex, Follistim, and Gonal-F are the most often used brands (these are also self-administered injections).

The donor will be monitored during this 8-11 day period (via blood tests and vaginal ultrasounds) to ensure that her follicles are growing at an expected rate and to monitor medication dosages. This monitoring will help the physician determine what day the final HCG injection should be administered (see next step). The donor will again be screened for STDs (via blood tests) during this time.

When the follicles are determined to be "ready" for retrieval, the HCG injection is given, which prepares the donor's ovaries to release the eggs. This injection is generally injected in the muscle (clinical requirements may vary), so the needle may be somewhat longer than it has been for previous medications. The physician will inform the donor of the exact time she should administer this injection. The timing of the HCG injection is crucial, so it is important that the donor take the injection exactly as instructed.

The retrieval is scheduled for 36-40 hours after administration of the HCG injection.

During the retrieval, the donor will usually be under light anesthesia and the eggs are retrieved from the donor's ovaries via a "vacuuming procedure:" a tiny needle is inserted through the vaginal wall into the ovaries and the eggs are vacuumed from each follicle. While under anesthesia, the donor should not feel anything during this procedure. The entire procedure itself takes only 15-30 minutes. It is the donor’s responsibility to arrange for a companion to travel with her to and from the retrieval procedure, since she will be unable to travel alone the day of the retrieval. If this is a problem, she must make alternative arrangements with the embryo bank prior to signing her egg donor contract to ensure that appropriate arrangements can be made.

10.

After the eggs have been retrieved, they are combined with the sperm donors' sperm to fertilize as many eggs as possible.

11.

After the procedure, the donor will remain at the clinic for 1-2 hours to recover from the anesthesia, after which she can return home. The donor will be expected to rest for the remainder of the day, as she may feel some bloating, cramping and other side effects the day of the retrieval. It is required that the donor arrange for a companion to drive her home after the retrieval. Further, it is highly suggested that her companion stay with her throughout the day, in the event that she experiences unexpected complications. Again, it is the donor’s responsibility to make arrangements for this companion.

12.

The donor will receive the remainder of her compensation within a week after the retrieval, once our agency has been informed that the retrieval is complete.

13.

Donors typically resume all normal activity, with the exception of physically strenuous activity or exercise, the day after the retrieval procedure.

Compensation

The Embryo Bank will offer donors appropriate compensation for their efferts. According to the American Society for Reproductive Medicine (ASRM), appropriate and suggested compensation for Donors is $5,000. Lost wages and/or childcare expenses associated with the egg donation process are encompassed in the donor compensation.

Expenses

The Embryo Bank is responsible for the following expenses:

All Medical Expenses

Donor Compensation

Attorney Fees

Accidental Donor Insurance

Side Effects/Risks

There are several side effects and risks that may be associated with being a donor. These side effects and risks are as follows:

Side effects that donors may or may not experience from the medications include: headaches, mood swings, bloating, nausea, and/or temporary stinging where the injection was administered. Donors can expect to feel particularly bloated during the immediate period before and after the retrieval, since the hormone medications they take will cause their ovaries to swell and produce many eggs. Donors may also experience temporary weight gain (e.g., several lbs.) until their next menstrual cycle, as a result of this bloating.

If the donor over-stimulates she may run the risk of Ovarian Hyperstimulation Syndrome, which is quite rare (occurs in less than 5% of Donors). Severe cases of this syndrome may result in damage to the donor's ovaries. In less severe cases, donors may experience severe bloating and strong cramping. If you show symptoms consistent with hyperstimulation, your physician may reduce your medication dosage or terminate the egg donation cycle to avoid medical complications.

With regard to the retrieval procedure, donors are exposed to the same risks as they would be if they were undergoing any other routine invasive procedure utilizing anesthesia. Donors will be instructed to rest the day of the retrieval, but most donors return to their normal daily activities, with the exception of physically strenuous activities or exercise, the day following the retrieval.

Potential Long Term Risks:

Empirical studies have not demonstrated any definitive link between egg donation and infertility, cancer, or any other significant long-term health problems. Since egg donation is a relatively new procedure, however, we hope to learn more about the long-term effects of egg donation in the future when additional research becomes available.

IMPORTANT NOTE:

Prior to beginning an egg donation cycle, it is highly recommended that donors thoroughly discuss all potential risks and side effects with the fertility physician they are assigned to work with.

DIRECTIONS FOR APPLICATION SUBMISSION

1) Make sure you read through the entire Egg Donor Information and Application Packet thoroughly and that you understand it completely before submitting an Egg Donor Application.

2) Complete the application either electronically (e.g. via computer) or via pen and paper. It is preferred that you complete the application electronically if possible. If completed electronically, please email completed application to embryobank@bellsouth.net; if completed via pen and paper, please mail completed application to the address listed below.

3) Email or mail us a minimum of four recent photos, as well as a minimum of three childhood photos, of yourself. Each donor is required to submit a minimum of: two recent close-up face photos, two recent full-length photos, one baby photo, one childhood photo, and one adolescent photo. These photos will be posted in our online donor database at the discretion of the Embryo Bank. We prefer that you scan the photos, save them as .jpeg or .gif files, and email them to us. If you only have hard copies of the photos, please mail them to us at the address below and we will scan them and return them to you upon request Please note that we will crop out any person other than yourself from all photos.

4) Mail us a copy of your driver’s license or other valid photo identification card. Please make sure the copy is legible. This document will be kept confidential and will not be shared with any other parties - we only use it to verify your identity. Please do not scan/email or fax us your photo ID, as we require that a hard copy be mailed to us.

5) Sign and return the Commitment Agreement found at the beginning of this application, in addition to the two consent forms found at the end of this application. Signed original forms must be mailed to us. Please do not scan/email or fax us these forms, as we require that hard copies be mailed to us.

6) Mail us copies of all your standardized test score reports (SAT, ACT, GRE, LSAT, Bagrut) and college transcript(s), both undergraduate and graduate. Please do not scan and email us these reports and transcripts, as we require that hard copies be mailed to us.

Please email materials to: embryobank@bellsouth.net

Please mail materials to:

The Embryo Bank

10913 Parkside Drive NW

Suite 304

Knoxville, Tennessee 37934

The Embryo Bank

embryobank@bellsouth.net

www.jewisheggdonor.net

Egg Donor Application Checklist:

Egg Donor Information and Application Packet has been completely read and understood.

3 Signature Pages (we require signed hard copies)

1) Commitment Agreement

2) Confirmation of Application Information

3) Release of Photo and Donor Profile

Completed Egg Donor Application.

Photos:

Minimum of two recent close-up photos

Minimum of two recent full-length photos

Minimum of one baby photo

Minimum of one childhood photo

Minimum of one adolescent photo

Photocopy of driver’s license or valid photo identification card.

Standardized test score reports and college transcripts.

Donor# __________ (for office use only)

To complete your application submission, The Embryo Bank must receive a signed hard copy of this form. We cannot accept electronic or faxed copies of this form

The Embryo Bank Commitment Agreement

Please do not submit an Egg Donor Application unless you are absolutely certain that you are ready to commit to being a donor. If you have any hesitations, concerns, or questions before submitting your application, please contact us and we will be happy to address these with you. Your application submission along with thorough reading of this Egg Donor Information packet indicates to us that you have informed yourself about egg donation and are comfortable and ready to proceed with a donation cycle.

I have read the above and thoroughly understand the commitment I am making.

Donor’s Printed Full Name: _________________________________

Donor Signature: _________________________________________

Date: _____________________

The Embryo Bank Employee Signature:

_________________________________________

Date: _____________________

The Embryo Bank

Egg Donor Application

Donor# __________ (for office use only)

Note: This information is for office and clinic use only and will not be released to the Intended Parents. Your confidentiality is extremely important to us.

Face Sheet (to be released to Fertility Clinic, but not to Intended Parents):

Last Name:

First Name:

M.I.:

Maiden name or any other names used:

Date of Birth:

Social Security Number:

Home Address:

Street:

City:

State:

Zip code:

Current Mailing Address (if different than above):

Street:

City:

State:

Zip code:

Home phone number:

Can we leave you messages at this phone number?

Cell Phone Number:

Can we leave you messages at this phone number?

Work Phone number:

Can we contact you at work?

Can we leave you messages at your work phone number?

Email Address:

Marital Status (check one – place check to the LEFT of your choice):

____Single ____Married ____Separated ____Divorced ____Partner (boyfriend/girlfriend) ____Widow

Spouse’s or Partner’s Full Name (if applicable):

In case of an emergency, whom should we contact?

What is his/her relationship to you?

Emergency Contact’s Phone Number(s):

The Embryo Bank

Donor# __________ (for office use only)

Miscellaneous Information Section I (to be released to the Embryo Bank only):

Date of Application Submission:

When will you be available for an egg donation?

Do you have any scheduling restrictions?

How did you hear about the Embryo Bank?

Would you be interested in being considered for a surrogacy program?

The Embryo Bank

Donor# __________ (for office use only)

Miscellaneous Information Section II (to be released to Embryo Bank only):

Have you traveled or resided outside of the United States for any period of time longer than 3 months at a time during your lifetime? If so, when and where? Please be as detailed as possible.

Have you had any tattoos, piercing, blood transfusion etc in the last 12 months? If so, when? (Note: donors cannot have received any tattoos, body piercing or blood transfusion during the 12 months prior to initiating screening for an egg donation)

Does your sexual partner/husband understand that s/he may also be required to undergo screening (blood tests) to make sure he is free of Sexually Transmitted Infections, HIV, and other communicable diseases? Your partner/husband understands that s/he may be required to travel WITH you to the clinic for a day?

Have you ever had a blood transfusion? If so, when and why?

Have you ever received growth hormone made from human pituitary glands?

Have you ever had a dura mater transplant?

Have any of your blood relatives ever had Creutzfeldt-Jakob disease?

The Embryo Bank

Donor# __________ (for office use only)

To be released to Intended Parents and posted on Embryo Bank online Donor Database:

Month & Year of Birth:

State of Residence:

Current Occupation:

How long have you been employed in this occupation?

Marital Status (check one – place check to the LEFT of your choice):

____Single ____Married ____Separated ____Divorced ____Partner (boyfriend/girlfriend) ____Widow

Do you drive and have a valid driver’s license? Do you own a car?

Do you have medical insurance?

What is your religion and are you currently practicing this religion?

Are you adopted?

If so, do you have information about your biological family?

Do you have any legal cases pending against you? If so, please explain.

Have you ever filed bankruptcy?

Have you been convicted of a crime? If so, please explain.

Do you prefer to do an anonymous donation? Do you prefer, or are you willing, to talk to or meet the Intended Parents? Please elaborate:

Are you willing to donate to international Intended Parents?

Are you willing to donate to a single Intended Parent?

Are there any types of Intended Parents who you will not donate to? If so, please elaborate:

If you are an experienced Egg Donor, please complete the following section:

Date	Clinic/Doctor	# Eggs Retrieved	# Embryos	Pregnancy?	Type of Pregnancy (single, twins, etc.)

Have you told your family and friends about your decision to donate? If so, who have you told and are they supportive of your decision?

Do you currently smoke?

Have you ever smoked in the past? If so, list approximately dates during which you smoked and how frequently you smoked (e.g. number of cigarettes or packs per day or week):

Have you had and/or been treated for a substance/alcohol abuse/addiction problem?

Do you use illegal drugs?

Are you currently taking birth control pills? If so, what type?

Other than birth control pills, are you currently taking any prescription medication?

If so, please elaborate (name of medication, dosage, duration of use, purpose, etc.):

Do you take any herbal remedies or supplemental vitamins on a continual basis? If so, please describe.

Please list any surgeries or hospitalizations and dates they occurred?

Have you ever been under the treatment of a psychiatrist or psychologist for a psychological disorder? If so, please list approximately dates of treatment, treatment duration and reason(s) for treatment.

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Personal and Family Demographics

Ethnicity (please be as specific as possible):

Race:

Country of Origin:

Blood type & RH Factor (if unknown, please consult with your primary care physician to obtain this information or plan to obtain a blood type test, as it is important to some intended parents):

Height:

Weight:

Natural hair color:

Eye color:

Hair texture (check one – place check to the LEFT of your choice):

__straight ____curly ____thick ____thin

Skin tone (check one – place check to the LEFT of your choice):

____fair ____medium ____dark ____olive ____other

How would you describe your ability to tan? (tan easily, tend to sunburn, etc)

Build (check one – place check to the LEFT of your choice): ___ petite ____medium ____large

Have you ever worn braces? If so, during what age(s)?

Shoe Size:

Dimensions (Bust Measurements/Waist/Hips):

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Biological Mother

Ethnicity (please be as specific as possible):

Country of Origin:

Race:

Age:

Height:

Weight:

Eye Color: Natural Hair Color:

Hair texture (check one – place check to the LEFT of your choice):

____straight ____curly ____thick ____thin

Skin Tone (check one - place check to the LEFT of your choice)

___fair ___ medium ___olive ___dark ___other

How would you describe her ability to tan? (tan easily, tend to sunburn, etc)

Health Condition:

Personality Description:

Occupation:

College Degrees (if any):

Talents/Hobbies:

Number of Brothers:

Number of Sisters:

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Biological Father

Ethnicity (please be as specific as possible):

Country of Origin:

Race:

Age:

Height:

Weight:

Eye Color:

Natural Hair Color:

Hair texture (check one – place check to the LEFT of your choice):

____straight ____curly ____thick ____thin

Skin Tone (check one - place check to the LEFT of your choice)

___fair ___ medium ___olive ___dark ___other

How would you describe his ability to tan? (tan easily, tend to sunburn, etc)

Health Condition:

Personality Description:

Occupation:

College Degrees (if any):

Talents/Hobbies:

Number of Brothers:

Number of Sisters:

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NOTE: Please copy and paste additional sections if you have more than one sibling. Please also note if the sibling is a half-sibling. Please note that we do not require information regarding non-biological step or adopted siblings.

Biological Sibling of Donor

Gender:

Age:

Height:

Weight:

Eye Color:

Natural Hair Color:

Hair texture (check one – place check to the LEFT of your choice):

____straight ____curly ____thick ____thin

Skin Tone (check one - place check to the LEFT of your choice)

___fair ___ medium ___olive ___dark ___other

How would you describe his/her ability to tan? (tan easily, tend to sunburn, etc)

Health Condition:

Personality Description:

Occupation:

College Degrees (if any):

Talents/Hobbies:

Age and sex of children, if any:

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Biological Sibling of Donor

Gender:

Age:

Height:

Weight:

Eye Color:

Natural Hair Color:

Hair texture (check one – place check to the LEFT of your choice):

____straight ____curly ____thick ____thin

Skin Tone (check one - place check to the LEFT of your choice)

___fair ___ medium ___olive ___dark ___other

How would you describe his/her ability to tan? (tan easily, tend to sunburn, etc)

Health Condition:

Personality Description:

Occupation:

College Degrees (if any):

Talents/Hobbies:

Age and sex of children, if any:

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Biological Grandparents of Donor

Please complete the following chart with the requested information regarding your biological grandparents:

	Hair Color	Eye Color	Age	Countries of origin	Deceased?
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather

Academic Information

Please note that all college transcripts and standardized test reports must be submitted to Embryo Bank.

What degree(s) do you currently hold (e.g., high school diploma, Bachelor’s, Master’s, Ph.D., M.D., J.D., R.N., etc.):

High School GPA:

Year of high school graduation:

Did you receive any awards, honors, scholarships, etc. while in high school? If so, please elaborate:

Where you involved in any extra-curricular activities in high school? If so, please elaborate.

Which subjects did you enjoy most in high school?

SAT Scores:

Quantitative:

Verbal:

Bagrut Scores:

GRE Scores:

Quantitative:

Verbal:

Analytical:

LSAT Score:

ACT Score:

IQ Score (if known):

Name and dates of undergraduate college(s) attended (if any):

Undergraduate G.P.A.:

Major Area(s) of Study:

What year did you graduate or what year do you expect to graduate from your undergraduate program? If you started the program, but did not and will not complete it, please be sure to indicate this.

Did you receive any awards, honors, scholarships, etc. in your undergraduate program? If so, please elaborate:

Where you involved in any extra-curricular activities in your undergraduate program? If so, please elaborate.

Which subjects did you enjoy most in college?

Name and dates of graduate programs(s)/law school/medical school attended (if any):

Graduate Program G.P.A.:

Major Area(s) of Study:

What year did you graduate or what year do you expect to graduate from your graduate program? If you started the program, but did not and will not complete it, please be sure to indicate this.

Did you receive any awards, honors, scholarships, etc. in your graduate program? If so, please elaborate:

Where you involved in any extra-curricular activities in your graduate program? If so, please elaborate.

Medical Screening

Place a check or "X" next to any medical condition applicable to you or your family members. For any conditions endorsed for your grandparents, aunts, uncles, or cousins, please indicate whether they are from the maternal or paternal side of your family.

	You	Mother	Father	Sibling	Grandmother	Grandfather	Aunt/Uncle	Cousin
Wears Corrective Lenses
Stroke
Heart Attack
Heart Disease
High Blood Pressure
High Cholesterol
Anemia
Hemophilia or other bleeding disorder
Leukemia
HIV
Lymphoma
Environmental Allergies
Other Allergies
Asthma
Emphysema
Tuberculosis
Lung Cancer
Pneumonia
Stomach Ulcer
Gall Stones
Hepatitis A, B, C (please specify)

	You	Mother	Father	Sibling	Grandmother	Grandfather	Aunt/Uncle	Cousin
Cirrhosis
Colon Cancer
Ulcerative Colitis
Crohn’s Disease
Cystic Fibrosis
Pyloric Stenosis
Rectal Disorder
Diabetes Mellitus Type 1
Diabetes Mellitus Type 2
Thyroid Cancer
Thyroid Disease
Goiter
Adrenal Dysfunction/Disorder
Kidney Disease
Other Urinary Tract Disease
Prostate Cancer
Testicular Cancer
Uterine Fibroids
Ovarian Cysts
Cancer of cervix, ovaries, or uterus
2 or more miscarriages
Stillborn

	You	Mother	Father	Sibling	Grandmother	Grandfather	Aunt/Uncle	Cousin
Death of Newborn Baby
Neonatal Jaundice
Migraines
Mental Retardation
Down Syndrome
Multiple Sclerosis
Cerebral Palsy
Epilepsy/Seizures
Hydrocephalus
Spina Bifida/Neural Tube Defect
Huntington’s Disease
Alzheimer’s Disease
Parkinson’s Disease
Wilson’s Disease
Gaucher’s Disease
Canavan’s Disease
OCD, ADHD, ADD
Schizophrenia/Psychotic Disorder
Major Depressive Disorder
Bipolar Disorder
Alcoholism
Drug abuse/addiction
Male Pattern Baldness

	You	Mother	Father	Sibling	Grandmother	Grandfather	Aunt/Uncle	Cousin
Osteoporosis
Dwarfism
Arthritis
Gout
Myasthenia Gravis
Deafness before age 60
Blindness
Color Blindness
Eczema
Skin Cancer
Pigmentation Disorder
Neurofibromatosis
Cleft Lip/ Cleft Palate
Club Foot
Scoliosis
Tourrette’s Syndrome
Paraplegia
Muscular Dystrophy
Lupus
Turner Syndrome
Kleinfelter Syndrome
Breast Cancer
Cancer
Other:

IMPORTANT

Please elaborate on any medical conditions endorsed above. For any major medical conditions/illnesses endorsed, list age of onset, treatment required, the extent to which illness has been debilitating, recovery information, etc. Also, for all grandparents, aunts, uncles, and cousins that had/has an illness, list whether they are from the maternal or paternal side of your family:

Are there any other medical conditions in your family not addressed above that your Intended Parent(s) should be aware of?

Have you ever been screened to determine whether you are a carrier of a cystic fibrosis gene mutation?

Are you or any of your family members known carriers of a cystic fibrosis gene mutation?

Have you ever been tested for the Tay-Sachs gene mutation?

Are you or any of your family members known carriers of a Tay-Sachs gene mutation?

Have you ever been tested to determine whether you a carrier of sickle cell anemia?

Are you or any of your family members known carriers of sickle cell anemia?

Please list the deaths of any parents, siblings, aunts, uncles, and grandparents. Include the relationship of the individual to you (also specify whether paternal or maternal relative), age of death, and cause of death:

Do you exercise? If so, what type of exercise and how often?

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Sexual/Reproductive History:

Describe the typical length of your menstrual cycle (e.g., normal 28 days cycle? Shorter? Longer?):

How long does your menstrual cycle flow typically last?

Do you experience PMS-related symptoms before or during your period (e.g., cramping, bloated, etc.)? If so, please elaborate:

Have you or any of your family members been diagnosed with endometriosis?

Have you ever tested positive for a Sexually Transmitted Infection (STI)? If so, when and how was it treated?

Have you ever had an abnormal pap smear? If so, when and how was it treated?

Have you ever been pregnant?

Do you have children? Please elaborate (children’s gender and month/year of birth):

Have you ever experienced any pregnancy complications such as, pre-term labor, gestational diabetes, placenta previa, emergency cesarean section, preclampsia, etc?

Have you ever had an abortion? If so, please list dates:

Has anyone in your family given birth to fraternal or identical twins? If so, please elaborate:

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Personality Questions

Why have you decided to undergo egg donation?

Describe your personality as an adult:

Describe your personality as an adolescent:

Describe your personality as a child:

What is your "philosophy of life"?

What are your personal goals? Have you achieved any of these goals?

What personal achievement are you most proud of?

What is your:

Favorite color?

Favorite type of food?

Favorite movie?

Favorite type of music?

Favorite book?

What are your special interests/hobbies/talents?

Would you be willing to meet a child conceived as a result of your donation? Please elaborate:

Is there anything else you would like to tell Intended Parents interested an embryo from your egg donation?

Donor# __________ (for office use only)

To complete your application submission, Embryo Bank must receive a signed hardcopy of this form. We cannot accept electronic or faxed copies of this form.

Embryo Bank Confirmation of Application Information

Under penalty of perjury, I attest that all of the information I have provided in my Donor Application is true, to the best of my knowledge. I confirm that I have thoroughly read, understand, and agree to the information and Donor responsibilities described in the Egg Donor Information and Application Packet. Further, I confirm that I have had all of my questions pertaining to egg donation answered and feel that I am fully ready to proceed as an Egg Donor. I understand that I will be required to complete a new Egg Donor Application for Embryo Bank on an annual basis.

Donor’s Printed Full Name: _________________________________

Donor Signature: _________________________________________

Date: _____________________

Donor# __________ (for office use only)

To complete your application submission, Embryo Bank must receive a signed hardcopy of this form. We cannot accept electronic or faxed copies of this form.

Embryo Bank Release of Photo and Donor Profile

I authorize Embryo Bank to post my photos and Donor Profile on Embryo Bank online Donor Database.

Donor’s Printed Full Name: _________________________________

Donor Signature: _________________________________________

Date: _____________________