New Donor Initial Application

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.

Instructions:

1. Please fill in all blanks completely. Please complete all questions and write “N/A” if not applicable.
2. Please be specific. Avoid expressions such as “natural” or “old age” (for causes of death). List any health problems as specifically as possible. If you do not know the age, put the approximate age or ask a relative to help you. List exact relationships such as “first cousin through my mother’s sister”.
3. Please provide information on all the relatives requested. Do not write their names.
4. If you have any questions, please call your donor coordinator.

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:

1. I have submitted a written application to Elite Fertility Solutions. Inc., (hereinafter “EFS”), wherein I have requested the assistance of EFS in pursuit of my desire to donate ovum (eggs) to Intended Parents.
2. In connection with my application to EFS I have provided certain medical, social, ethnic, physical characteristic and other background information about myself and my genetic background. I agree to undergo Genetic Screening upon selection and will be advised of the results of the screening should I test positive as a carrier.
3. I understand, agree, and hereby confirm that I have been informed by EFS that prospective and actual Intended Parents will rely on the accuracy of the information which I have provided. I further confirm that I have been instructed by EFS that I must provide accurate and complete information about my background and health history.
4. I understand that I must use one of the recommended methods of contraception while being a donor with EFS. These methods include birth control pills, Nuva Ring, a Standard Copper IUD (not Mirena), birth control patches or condoms. (Per physician instruction)
5. I have been informed by EFS that the information which I have provided along with my questionnaire, psychological evaluation and photos, may be reproduced and distributed on the Elite Fertility Website to prospective and/or actual Intended Parents. I have further been informed that although EFS will not release my name to prospective or actual recipients, that my identity may be discovered by some other means.
6. I understand that once selected by a prospective Intended Parent I will be referred to an attorney who will (at no charge to me) explain the legal significance and legal consequence of my anticipated donation. I understand that it is exclusively my responsibility to obtain answers to any of my legal questions. I confirm that I have been informed that EFS makes no representations regarding the legal consequences of my anticipated donation. I further agree that I have been informed by EFS that I may seek independent legal advice of my own choosing and at my own expense.
7. I have been informed that it is entirely my responsibility to obtain tax advice from my own advisors regarding the nature and characterization of any payments of money that I receive in connection with the donation of my oocyte (egg).
8. I have been informed and instructed by EFS that it is entirely and exclusively my responsibility to seek all appropriate medical information from my own physician(s) concerning the egg donation procedure. I understand that it is exclusively my responsibility to obtain information regarding any risks associated with the egg donor procedure, including physical, psychological or any other risk(s).
9. I understand and agree that EFS may at any time and without prior notice to me, cease any and all efforts to assist me in being selected as a prospective donor.

The undersigned prospective egg donor applicant does hereby acknowledge, agree and authorize Elite Fertility Solutions, Inc., its officers, directors and/or employees. as follows:

1. I understand that non-identifying information concerning my health and social history, physical characteristics, age, marital status and ethnic background. will be released by Elite Fertility Solutions, Inc., to prospective Intended Parents. I hereby authorize the release (by any and all means) my written information as well as photographs contained in my files at Elite Fertility Solutions, Inc., to Intended Parents.
2. I understand, acknowledge and agree that although Elite Fertility Solutions, Inc., will not release my name, address or phone number to any Intended Parents. It is possible that I will be recognized and identified as a prospective donor based upon the photographs which I have provided and which I have authorized to be released by Elite Fertility Solutions, Inc. I therefore acknowledge that Elite Fertility Solutions, Inc., its officers, directors and employees cannot and do not guarantee me anonymity.

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 mental health.