To become an egg donor, we need to learn some information about your personal and medical history. Your responses to these questions are to ensure that your health and medical history are compatible with the donation process and will not involve any increased risks to you. This effort will also help us to match you to the appropriate Intended Parent
Please provide complete and accurate information to these questions. If you do not know the answer, ask a parent or family member. Any information you provide during the donation process, will remain completely confidential. Some of the information from this questionnaire will be given to the recipient(s) as noted but all identifying information is removed.
A "yes" response will not necessarily eliminate you as a potential donor. Most people will have at least one of these conditions in themselves or a family member. The accuracy of the information you will be giving will provide information to potential families you may help to create.
I hereby attest that all information disclosed in this application is accurate, true, and up-to-date to the best of my knowledge.
I, the undersigned prospective egg donor applicant, declare as follows:
The undersigned prospective egg donor applicant does hereby acknowledge, agree and authorize Elite Fertility Solutions, Inc., its officers, directors and/or employees. as follows:
This Release and Authorization shall remain effective for eighteen 18) months following the date of execution hereof, unless sooner revoked by the undersigned in writing.
I hereby authorize Elite Fertility Solutions to release all medical information pertaining to and relating to any prior
donor IVF cycles to Fertility Clinics as it relates to future donations.
I understand and agree that said information that is disclosed under this authorization may subsequently be released
and disclosed again by ELITE FERTILITY SOLUTIONS at their discretion. Therefore, the privacy of this information
may not be protected under the Federal Privacy Regulation. Prior to signing this release, I have been advised that I
have the right to have this release and the consequences thereof reviewed by an attorney of my own choosing.
I understand that specific information to be released may include AIDS or HIV, alcohol and/or drug abuse and