New Donor Initial Application

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*
Date Format: 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

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Uniform Donor Application Form
Donor Name*
First Last
Date*
Date Format: 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:
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.

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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

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Have you ever used recreational or illicit drugs (cocaine, marijuana, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids, or etc.)?*
- Yes
- No
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
- No
Please list and describe all of your tattoos and body piercings:*
Date Description Location on Body Sterile Needles Used?

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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
- No

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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
- No
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?

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Menstrual History
Date of last Pap Smear
Date Format: MM slash DD slash YYYY
Result*
Have you ever had an abnormal PAP?*
- Yes
- No
If yes, when & why?*

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DECLARATION OF EGG DONOR APPLICANT
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.
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:*
Date Format: DD slash MM slash YYYY

Please enter Date.
in the City of*
Signature*
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.

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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:
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.
Prospective Egg Donor Name*
First Last
Prospective Egg Donor Name (Signature)*
Date*
Date Format: MM slash DD slash YYYY

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Egg Donor Release of Medical Records
Date*
Date Format: MM slash DD slash YYYY
Patient Name:*
First Last
Date of Birth:*
Date Format: 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*
Date Format: MM slash DD slash YYYY

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New Donor Initial Application

Step 1 of 11 - Donor Demographics

Donor Demographics

Insurance

Uniform Donor Application Form

Personal History

Personal History

Sexual History

Contraceptive History

Menstrual History

FDA Donor Questionnaire

DECLARATION OF EGG DONOR APPLICANT

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

Egg Donor Release of Medical Records

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949.494.6511

Medication	How Often	Reason

Date	Description	Location on Body	Sterile Needles Used?