donor Donor
donor
donor Donor

 

General Information
Username (must be 6 characters or more)
Password (must be 6 characters or more and contain 1 number and 1 uppercase)
Verify Password        
           
Partner 1 First Name: Last Name: Gender:
Partner #2 First Name: Last Name: Gender:
Address:
City: State: Zip:
Home Phone: Fax:
Partner #1 (Work) Partner #2 (Work)
Partner #1 Cell Phone: Partner #2 Cell Phone:
Partner #1 Email
Partner #2 Email:
Occupation:
Partner #1:    
Partner #2:    
Age:
Partner #1: Partner #2:
Marital Status: How Long?
Who is your fertility clinic?
Who is your fertility specialist?
Will spouse/partner be biological father?
If no, is the sperm donor:
How did you hear about The Egg Donor Program?
Already scheduled an appointment for a consultation?
Consultation Date:
Consultation Time: (Please format as hh:mm:ss)
Previous Recipient?
donor donor
donor Donor
Physical Characteristics
Partner #1 Partner #2
Height
Weight
Hair
Eyes
Ethnicity
Educational Background
Please describe yourself with 4 or 5 adjectives:
Partner #1:
Partner #2:
Please list your interests, hobbies and activities:
Partner #1:
Partner #2:
Please list several qualities you think would be important in a donor:
Wish for contact with the donor:
donor donor
donor Donor
Previous Children
Partner #1 Partner #2
Number Boys
Boys Ages
Number Girls
Girl Ages
donor donor
donor Donor
Fertility History
How many years have you experienced infertility?  
Is this your first donor procedure?  
(Please comment on the outcomes of the other procedure(s): # of embryos, miscarriages, chemical pregnancy, etc.)
How long have you been considering egg donation?
Please discuss the following questions together and then record your responses on a scale of 1 to 10, with  10 being the HIGHEST and 1 being the LOWEST:
Partner #1 Partner#2
How would you rate your:
Comfort level with ovum donation
Level of hope for success with ovum donation
Satisfaction in your relationship
Commitment to becoming parents
Level of depression regarding infertility
Level of anxiety regarding infertility
donor donor
donor Donor
Health History
Have you had previous individual or group therapy?
If so, how long?
Was the individual or group therapy specifically to help support you during your infertility procedures?
Have you ever been on medication for any psychological condition?
If so, how long and what was the medication?
Is there any history of mental illness in either of your families?
If so, which family member and what was the mental illness?
Have either of you been accused and/or convicted of a crime in anyway related to child abuse?
Have either of you ever been accused and/or convicted of child abuse.; If so explain:
donor donor
donor Donor
Agreement

I certify that the information on this application is correct and may be subject to verification.

 

*You will be counseled regarding donation issues; outside referrals will be given for independent psychotherapy when appropriate.
Please do not hesitate to call with your concerns. Good Luck!



All information obtained is kept strictly confidential.  We do not sell or exploit your personal information in any way.

Please note that before the time of your consultation, we need to have the following:
1) Your complete application
2) A photo of both you and your spouse

 
donor donor
donor donor