New Donor Initial Application

"*" indicates required fields

Step 1 of 11 – Donor Demographics

Donor Demographics

Name*

First Last

Home Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address (if different from above)

Street Address Address Line 2 City State ZIP Code

Home Telephone*

Work Telephone

Ext

Cell Phone

Fax: “Private”

Email*

Date of Birth*

MM slash DD slash YYYY

Social Security Number*

Driver’s License Number

Employer/Occupation*

Marital Status*

Single

Married

Divorced

Widowed

Emergency Contact Name*

Emergency Telephone*

Relationship*

Insurance

Primary Insurance Company

Insurance Company Address

Phone Number

Fax Number

Policy Holder Name

Relationship to Donor

Insured’s Employer

Phone Number

Group Name/Number

Uniform Donor Application Form

Donor Name*

First Last

Date*

MM slash DD slash YYYY

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:

Please fill in all blanks completely. Please complete all questions and write “N/A” if not applicable.
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”.
Please provide information on all the relatives requested. Do not write their names.
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.

Personal History

Are you currently under a physician’s care for any reason?*

Yes

If yes, please explain:*

Have you had any serious illness in the past?*

Yes

If yes, please describe:*

Did you have any complications or concerns with anesthesia?*

Yes

If yes, please describe:*

Have you ever been seen by psychiatrist, psychologist, social worker, counselor, or any other mental health professional for any reason?*

Yes

If yes, when, for how long and for what reason?*

Have you ever used medications such as anti-anxiety or antidepressants to treat an emotional or psychological problem?*

Yes

If yes, list why, medication and date last used*

Have you ever been refused or denied as a blood donor?*

Yes

If yes, why?*

Personal History

List all current over-the-counter medications (include hormones, vitamins, aspirin, antacids, laxatives, herbal & sports supplements, performance-enhancing supplements including steroids, etc.):*

Medication

How Often

Reason

Click + Icon to add more.

Have you ever used recreational or illicit drugs (cocaine, marijuana, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids, or etc.)?*

Yes

If yes, which one (s) and when did you last use them?*

Have you ever had your ear and/or body piercing or tattooing in which sterile needles may not have been used?*

Yes

Please list and describe all of your tattoos and body piercings:*

Date

Description

Location on Body

Sterile Needles Used?

Sexual History

Number of current sexual partners:*

Number of sexual partners during the past 12 months:*

Length of current relationship:*

Years

Months

In the last 6 months have you had unprotected sex (intercourse without a condom)*

Yes

Contraceptive History

Currently use:*

IUD

Diaphragm

Condom

Birth Control Pills

Rhythm

Abstinence

Depo-Provera

Tubal Ligation

None

Birth Control Name*

How long have you been on Birth Control Pills?*

If Depo-Provera, when was your last injection?*

If IUD, what type?*

Have you or any of your sexual partners been treated for any of the following*

Yes

HIV (AIDS)

Self

Partner

How Many Times?

When was the lst time?

NSU (nonspecific urethritis)

Self

Partner

How Many Times?

When was the lst time?

Syphilis

Self

Partner

How Many Times?

When was the lst time?

Gonorrhea

Self

Partner

How Many Times?

When was the lst time?

Chlamydia

Self

Partner

How Many Times?

When was the lst time?

Trichomonas

Self

Partner

How Many Times?

When was the lst time?

Venereal Warts

Self

Partner

How Many Times?

When was the lst time?

Herpes, Genital

Self

Partner

How Many Times?

When was the lst time?

Genital Sores

Self

Partner

How Many Times?

When was the lst time?

Viral Hepatitis B or C

Self

Partner

How Many Times?

When was the lst time?

HPV

Self

Partner

How Many Times?

When was the lst time?

Menstrual History

Date of last Pap Smear

MM slash DD slash YYYY

Result*

Have you ever had an abnormal PAP?*

Yes

If yes, when & why?*

FDA Donor Questionnaire

In the past 12 months, have you had sex with a man who has had sex with another man in the past 5 years?*

Yes

Unsure

Comments

Have you injected drugs for a non-medical reason in the last 5 years, including in ravenous, intramuscular and subcutaneous injection?*

Yes

Unsure

Comments

Have you received humanderived clotting factor concentrates for hemophilia or a related clotting dis order?*

Yes

Unsure

Comments

In the past 5 years, have you been given money or drugs in exchange for having sex?*

Yes

Unsure

Comments

In the past 12 months, have you had sex with anyone who would answer yes to any of Questions 1, 2, 3 or 4?*

Yes

Unsure

Comments

In the past 12 months, have you had sex with a person known or suspected to have HIV infection, active hepatitis B infection or hepatitis C infection, clinically active hepatitis B infection, or hepatitis C infection?*

Yes

Unsure

Comments

In the past 12 months, have you been exposed to known or suspected HIV, hepatitis Band/or hepatitis C infected blood through percutaneous inoculation (e.g., needlestick) or through contact with an open wound, non-intact skin or mucous membrane?*

Yes

Unsure

Comments

In the past 12 months have you had an accidental needle stick, sharp instrument injury, contact with human blood, serum or plasma in the eye, mucus membranes (lips interior of nose) or sores*

Yes

Unsure

Comments

In the past 12 months, have you been in jail for more than 72 consecutive hours?*

Yes

Unsure

Comments

In the past 12 months, have you lived with (resided in the same dwelling) another person who has Hepatitis B or clinically active (symptomatic) Hepatitis C infection?*

Yes

Unsure

Comments

In the past 12 months, have you had ear or body piercing or tattooing?*

Yes

Unsure

Comments

Were sterile instruments used?*

Yes

Unsure

Comments

Did you have ear, skin or body piercing performed in the past 12 months?*

Yes

Unsure

Comments

Were sterile instruments used?*

Yes

Unsure

Comments

After age 11 have you had a clinical diagnosis of symptomatic viral hepatitis?*

Yes

Unsure

Comments

Was the hepatitis identified as Hepatitis A (e.g. reactive IgM antiHA V test), Epstein -Barr, or cytomegalovirus?*

Yes

Unsure

Comments

Have you, your sexual partner(s) or any member of your household ever had a transplant or medical procedure that involved being exposed to live cells, tissues or organs from an animal?*

Yes

Unsure

Comments

If the person referred to in question 13 was a member of your household, were you exposed to that individual's blood, saliva or other body fluids (e.g., through deep kissing, shared toothbrushes, razors, or needles, or through open wounds or sores)*

Yes

Unsure

Comments

Have you been diagnosed with West Nile Virus (including diagnosis based on symptoms and/or laboratory results, or confirmed WNV viremia) in the past 120 days?*

Yes

Unsure

Comments

Have you been suspected of having West Nile Virus in the past 120 days?*

Yes

Unsure

Comments

Within the past 8 weeks, have you had a smallpox vaccination or had close contact with the vaccination site of anyone else? (Examples of close contact include touching the site, the bandages covering the site or handling bedding or clothing that has been in contact with an unbandaged vaccination site.)*

Yes

Unsure

Comments

Did you have a smallpox vaccination?*

Yes

Unsure

Comments

Did scab separate/fall off by itself?*

Yes

Unsure

Comments

If you had close contact with a smallpox vaccination recipient, have you had any new skin rash or sore since the time of contact?*

Yes

Unsure

Comments

Did scab fall off/separate spontaneously?*

Yes

Unsure

Comments

Did you have any illness or complications from your vaccination or from your close contact with someone who was vaccinated?*

Yes

Unsure

Comments

In the past 12 months have you had or been treated for syphilis, chlamydia or gonorrhea?*

Yes

Unsure

Comments

Have you or any of your blood relatives been diagnosed with Creutzfeld-Jakob disease (CJD)?*

Yes

Unsure

Comments

Have you been diagnosed with dementia or any degenerative or demyelinating disease of the central nervous system or other neurological disease of unknown Etiology?*

Yes

Unsure

Comments

Have you ever received growth hormone made from human pituitary glands?*

Yes

Unsure

Comments

Have you ever received a nonsynthetic dura mater (brain covering) graft?*

Yes

Unsure

Comments

From 1980 through 1996 were you a member of the U.S. military, a civilian military employee or a dependent of a military member or civilian military employee?*

Yes

Unsure

Comments

Did you spend a total of 6 months or more associated with a military base in any of the following countries, Germany, Belgium, or the Netherlands between 1980 and 1990; or Greece, Turkey, Spain, Portugal, or Italy between 1980- 1996?*

Yes

Unsure

Comments

Since 1980, have you ever lived in or traveled to Europe? (Includes Albania, Austria, Belgium, BosniaHerzegovina, 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, and Yugoslavia)*

Yes

Unsure

Comments

From the beginning of 1980 through the end of 1996 did you spend time that adds up to 3 months or more in the U.K.? (Includes England, Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar and the Falkland Islands)*

Yes

Unsure

Comments

Since 1980 have you received a transfusion of blood or blood components in the U.K. or France?*

Yes

Unsure

Comments

Since 1980 have you spent time that adds up to 5 years or more in Europe (including time spent in the U.K. between 1980 and 1996)?*

Yes

Unsure

Comments

Have you ever been to or had sexual contact with anyone who was born in or lived in certain countries in Africa (Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria) after 1977?*

Yes

Unsure

Comments

Have you received a blood transfusion or any medical treatment that involved blood in the countries listed in Question 24?*

Yes

Unsure

Comments

Have you had a medical diagnosis of ZIKA virus in the past 6 months?*

Yes

Unsure

Comments

Have you resided in or traveled to an area with active ZIKA virus transmission within the past 6 months? (Includes Cape Verde, Caribbean, Central America, Mexico, Pacific Islands, South America or Rio2016 Olympics)*

Yes

Unsure

Comments

Have you had sexual contact in the past 6 months with a male who is known to have either of the risk factors listed in # 26 or # 27 above*

Yes

Unsure

Comments

DECLARATION OF EGG DONOR APPLICANT

I, the undersigned prospective egg donor applicant, declare as follows:

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.
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.
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.
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)
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.
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.
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).
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).
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.

Applicant Name*

First Last

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed this:*

DD slash MM slash YYYY

Please enter Date.

in the City of*

Signature*

I, the undersigned prospective egg donor applicant, declare as follows:

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.
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.
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.
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)
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.
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.
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).
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).
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.

ELITE FERTILITY SOLUTIONS AUTHORIZATION FOR RELEASE OF NON-IDENTIFYING INFORMATION AND PHOTO(S)

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

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.
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.

Prospective Egg Donor Name*

First Last

Prospective Egg Donor Name (Signature)*

Date*

MM slash DD slash YYYY

Egg Donor Release of Medical Records

Date*

MM slash DD slash YYYY

Patient Name:*

First Last

Date of Birth:*

MM slash DD slash YYYY

SS#*

Expiration Date of Authorization: 5 years from date of signed release.

I hereby authorize (Clinic or Office) to release to ELITE FERTILITY SOLUTIONS any and all medical information pertaining to and relating to any prior donor IVF cycles that I have undergone at said office.*

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.

Name of Patient*

First Last

Signature*

Date*

MM slash DD slash YYYY