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Egg Donor Application

If you have already submitted the initial application and wish to continue log in here.

This confidential application does not commit you to our program. Our Donor Program Coordinator will contact you within five business days to notify you of the status of your application and set up a telephone consultation to further discuss your qualifications. Please ensure that the email address you provide is accurate and functional. If you do not receive email confirmation in two business days, please call 408-355-1602, after you have checked your junk-mail folder.

We sincerely appreciate your honesty and completeness in filling out the Initial Application.

Contact Information

*:
*:
*:
At which numbers
may we leave a detailed
personal message?
At which numbers may we leave a detailed personal message?

 

Personal Information

Date of Birth*:
Race:
Race










Are you currently registered with any other egg donation programs?
  
Have you ever been an egg donor before?
  
Would you be willing to undergo frequent blood testing during the egg donation process? (about 6 to 10 times)
  
 

Marital Status

Does your partner, if any, support your desire to become an egg donor?
   
Would your partner, if any, be willing to have a blood test for infectious diseases?
   
Would you and your partner, if any, be willing to abstain from intercourse entirely for about 4 weeks during the egg donation process?
   
Would you and your partner, if any, be willing to commit to remaining monogamous for about 3 months during the egg donation process?
   
 

Education

 

Employment

With advanced notice, is your work, school or personal schedule flexible enough to allow for several 30-minute appointments, before 9:00am, during a two week period?
  
 

Health and Social History

Height:
lbs
Are you willing to take a break from vigorous activity for about 3 weeks during the egg donation process?
  
Have you ever had a miscarriage?
   
Have you ever had an abortion?
   
Have you ever delivered a baby?
   
Are you adopted?
  
Are you currently using a hormonal form of contraception?
(Answering yes does not disqualify you from donating eggs)
  

Do you have an IUD?
(Answering yes does not disqualify you from donating eggs)
  

Have you ever tested positive for HIV or Hepatitis?
  

Have you ever been denied as a blood donor?
  

Have you ever been arrested?
  

How many alcoholic beverages do you consume on weekly basis?

Do you take any herbal, prescription or over-the-counter medications?
  

Do you use any illicit drugs or narcotics?
(urine drug screening will be performed)
  
Do you currently smoke?
(urine nicotine screening will be performed)
  
Have you ever smoked?
  
Are you willing to commit to being completely smoke free from now until you are no longer an egg donor?
  
 

FDA Medical History Evaluation for Anonymous Oocyte Donors

Effective May 25, 2005 the Food and Drug Administration (FDA) requires that the infectious disease health history be obtained from all egg donors. The questions in the following form reflect these requirements and are required to be answered truthfully, under federal law.
In the last 5 years, have you injected drugs for a non-medical reason? This includes intravenous, intramuscular and subcutaneous injections.
  
Have you ever used a human-derived clotting factor (for the treatment of hemophilia)?
  
In the last 5 years, have you engaged in sex in exchange for money or drugs?  
  
In the last 12 months, have you had intimate contact with any person described in the previous three questions (IV drug users, hemophiliacs, prostitutes) or with any person known or suspected to have HIV infection, clinically active hepatitis B infection, or hepatitis C infection?
  
In the last 12 months, have you had sex with a man who, during the last 5 years, has had sex with another man?
  
In the last 12 months, have you been exposed to blood, through a needle-stick, contact with an open wound, non-intact skin, or mucous membrane, that was either known or suspected to be infected with HIV, hepatitis B and/or hepatitis C?
  
In the last 12 months, have you been in juvenile detention, lock up, jail or prison for more than 72 consecutive hours?
  
In the last 12 months, have you had close contact with another person who has clinically active viral hepatitis (e.g., lived in the same household and regularly shared kitchen and bathroom facilities)?
  
In the last 12 months, have you had a tattoo, ear piercing, or body piercing in which instruments were shared or a sterile technique was not used?
  
Have you been diagnosed with viral hepatitis after age 11?
  
In the last 60 days, have you had a smallpox vaccination?
  
Do you currently have a clinically recognizable vaccinia virus (smallpox vaccination) infection contracted by close contact with someone who received the smallpox vaccine ?
  
Have you had a medical diagnosis of West Nile Virus infection and/or tested positive/reactive for West Nile Virus by a blood test?
  
Have you ever been diagnosed with Syphilis?
  
Have you ever been diagnosed with Chlamydia or Gonorrhea?
  
Have you ever been diagnosed with vCJD (Mad-Cow disease) or any other form of CJD?
  
Have you ever had a blood relative diagnosed with CJD?
  
Have you ever had a diagnosis of dementia or any degenerative or demyelinating disease of the central nervous system (CNS) or other neurological disease of unknown etiology?
  
Have you ever taken human pituitary-derived growth hormone?
  
Have you ever received a dura mater transplant?
  
Between January 1, 1980 and December 31, 1996, have you spent three months or more cumulatively in the United Kingdom? (England, Northern Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar, and the Falkland Islands)
  
Since January 1, 1980, have you lived in Europe for 5 or more years? (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, United Kingdom, and Yugoslavia)
  
Have you ever resided at any U.S. military bases in Northern Europe (Germany, Belgium, and the Netherlands) for 6 months or more from 1980 through 1990, or elsewhere in Europe (Greece, Turkey, Spain, Portugal, and Italy) for 6 months or more from 1980 through 1996?
  
Are you a dependent of someone who has resided at any U.S. military bases in Northern Europe (Germany, Belgium, and the Netherlands) for 6 months or more from 1980 through 1990, or elsewhere in Europe (Greece, Turkey, Spain, Portugal, and Italy) for 6 months or more from 1980 through 1996?
  
Have you received any transfusion of blood or blood components in the United Kingdom or France between 1980 and the present?
  
Were you or your intimate partner born the following African countries after 1977? (Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria)
  
Have you or your intimate partner lived in the following African countries after 1977? (Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria)
  
Have you or your intimate partner ever received any medical treatment or blood transfusion in the following African countries after 1977? (Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria)
  
Have you, your sexual partner, or any member of you/his/her household ever had a transplant or other medical procedure that involved being exposed to live cells, tissues, or organs from an animal?
  
Do you agree to notify FPNC immediately if any of the answers to the above questions change between now and the time of donation?