Egg Donor Program

Become an Egg Donor

If you've already registered, use the button below to continue:

Begin a New Donor Application

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See If You Qualify

Welcome to our easy online application. Step 1 will help you determine if you meet our minimum qualifications to become an egg donor.

Please Note: Field names in this color are required.

First Name

Middle Name

Last Name

E-mail Address

State

Home Phone

Can we leave private messages on this number?
Yes     No    

Work Phone

Can we leave private messages on this number?
Yes     No    

Cell Phone

Can we leave private messages on this number?
Yes     No    

Best Number to Be Reached At

Date of Birth
Month: Day: Year:
     

Height

Weight

Do you smoke or use tobacco in any form?
Yes     No    

Can you obtain accurate, up-to-date health information on your biological parents, grandparents and siblings?
Yes     No    

Health information includes illnesses, hospitalizations, or conditions requiring treatment by a medical specialist.

Are you currently taking any anti-depressant or anxiety medications such as Paxil, Zoloft, Lexapro, Prozac, Wellbutrin, Zyban, Effexor, Celexa, etc.?
Yes     No    

Have you ever been diagnosed with ADD/ADHD or any other type of learning disability?
Yes     No    

Have you, your parents, siblings, or children ever been diagnosed with any type of cancer before the age of 45?
Yes     No    
FDA Screening Questions

Please answer the following questions, which are required by the Food and Drug Administration.

1. Have you ever tested positive for the HIV virus, HTLV infection, hepatitis B virus or hepatitis C virus?
Yes     No    

2. To your knowledge, in the past 12 months have you engaged in oral, anal, or vaginal sex with a male who has had sex with another male?
Yes     No    

3. In the past 5 years have you or a sexual partner injected drugs or steroids for a non-medical reason?
Yes     No    

4. Do you have hemophilia or any other bleeding or clotting disorder?
Yes     No    

5. In the past 5 years have you engaged in sex in exchange for money or drugs?
Yes     No    

6. In the past 12 months have you engaged in sex with a person who has HIV; Hepatitis B, or a clinically active Hepatitis C infection?
Yes     No    

7. In the past 12 months have you been exposed to HIV, HBV, and/or infected blood through contact with an open wound, non-intact skin, or mucous membrane?
Yes     No    

8. In the past 12 months have you been in juvenile detention, lock up, jail or prison for more than 72 consecutive hours?
Yes     No    

9. In the past 12 months have you lived with someone who has Hepatitis B or clinically active Hepatitis C infection?
Yes     No    

10. In the past 12 months have you undergone tattooing, ear piercing or body piercing?
Yes     No    

11. Since your 11th birthday have you been diagnosed with clinical, symptomatic viral hepatitis?
Yes     No    

12. Have you had a smallpox vaccination in the last 8 weeks?
Yes     No    

13. To the best of you knowledge, have you been exposed to anyone who received a small pox vaccination?
Yes     No    

14. Have you had any other vaccination that resulted in complications?
Yes     No    

15. In the past 4 months have you had a medical diagnosis or suspicion of a West Nile Virus infection?
Yes     No    

16. In the past 4 months have you tested positive or reactive for a West Nile Virus infection?
Yes     No    

17. In the past 12 months have you been treated for or had Syphilis, Chlamydia, or Gonorrhea?
Yes     No    

18. Have you ever been diagnosed with any form of Creutzfeldt - Jakob disease (Mad Cow Disease)?
Yes     No    

19. Have you ever been diagnosed with dementia or a degenerative disease of the central nervous system?
Yes     No    

20. Have you ever received a non-synthetic dura transplant, human pituitary-derived growth hormone, or have any blood relatives diagnosed with Creutzfeldt - Jakob disease (Mad Cow Disease)?
Yes     No    

21. Have you spent more than three months cumulatively in England, Northern Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar, or the Falkland Islands from 1980 to 1996?
Yes     No    

22. Have you spent 5 or more years cumulatively in Europe from 1980-present?
Yes     No    

This includes the following countries: Albania, Austria, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Liechtenstein, Luxembourg, Macedonia, Netherlands, Norway, Poland, Portugal, Romania, Slovak Republic, Slovenia, Spain, Sweden, and Switzerland.

23. Are you a current or former U.S. military member, civilian military employee, or dependant of a military member or civilian employee?
Yes     No    

24. Did you receive any transfusion of blood or blood components in England, Northern Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar, Falkland Islands, Albania, Austria, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Liechtenstein, Luxembourg, Macedonia, Netherlands, Norway, Poland, Portugal, Romania, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria between 1980 Špresent?
Yes     No    

25. Were you or any of your sexual partners born or lived in Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria after 1977?
Yes     No    

26. To the best of your knowledge, have you or your sexual partner ever had a transplant or other medical procedure that involved being exposed to live cells, tissues or organs from an animal (including bone marrow, corneal, bone, skin or dura mater graft)?
Yes     No    

27. To the best of your knowledge has anyone in your household ever had a transplant or other medical procedure that involved being exposed to live cells, tissues or organs from an animal?
Yes     No    

28. Have you experienced weight loss other than through diet or exercise within the last 12 months?
Yes     No    

29. Have you experienced night sweats not due to elevated room temperature or sleeping conditions within the last 12 months?
Yes     No    

30. Have you experienced swollen lymph nodes for more than one month?
Yes     No    

31. Have you experienced purple or blue spots on your skin or in your mouth?
Yes     No    

32. Have you experienced fever of 100.5 degrees Fahrenheit or more for more than 10 days?
Yes     No    

33. Have you experienced unexplained persistent cough or shortness of breath?
Yes     No    

34. Have you experienced unexplained persistent diarrhea or unexplained persistent white spots on other lesions in the mouth?
Yes     No    

35. Have you experienced unexplained jaundice (yellow skin or eyes)
Yes     No    

36. Within the past month have you been diagnosed with SARS, had contact with a SARS infected individual or traveled to an area with SARS (Asia)?
Yes     No    

37. In the past 12 months, have you been under a doctor's care or had surgery or a major illness?
Yes     No    

38. Have you experienced any unexplained difficulty walking, pain, or change in behavior?
Yes     No    

39. Have you ever had cancer (including leukemia)?
Yes     No    

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