The Egg Donor Program - Online Application

General Information

Partner 1 First Name:

*Name Required

Last Name:

* Last Name Required

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?

Yes

If no, is the sperm donor:

Known

Unknown

How did you hear about The Egg Donor Program?

Already scheduled an appointment for a consultation?

Yes

Consultation Date:

Consultation Time:

(Please format as hh:mm:ss)

Previous Recipient?

Yes

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:

Previous Children

	Partner #1	Partner #2
Number Boys
Boys Ages
Number Girls
Girl Ages

Fertility History

How many years have you experienced infertility?

Is this your first donor procedure?

Yes

(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

Health History

Have you had previous individual or group therapy?

Yes

If so, how long?

Was the individual or group therapy specifically to help support you during your infertility procedures?

Yes

Have you ever been on medication for any psychological condition?

Yes

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?

Yes

Have either of you ever been accused and/or convicted of child abuse.; If so explain:

Agreement



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

Partner #1
Partner #2

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