Family Creations, LLC - International Egg Donor Program
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                      Donor Application
First Name:  
Last Name:  
Mailing Address:  
City:  
State:  
Zip Code:  
Email Address:    
Best Contact Phone Number:  
Message O.K.?
 
Second Contact Phone Number:  
Message O.K.?
 
How did you hear about us?  
Date of birth:      
Ethnicity:  
Height: ' "  
Weight:  
Hair    
Natural Color:  
Color at birth:  
Eye color:  
Do you smoke?
 
Do you drink, if so how often?  
Are you adopted?
 
Have you completed high school?
 
Are you currently a college student,
if so what is your major?
 
Do you have a college degree?
If so what was your major?
 
Occupation:  
Number of siblings:  
Marital status:  
Number of sexual partners
in the last year:
 
Number of sexual partners in your lifetime:  
Have you been an egg donor before?
 
What type of birth control are you presently using?  
Number of pregnancies:  
Number of children:  
When was your last pap smear?  
What were the results?  
Have you ever had an abnormal pap smear? If so, please explain:  
Have you or a partner of yours ever been diagnosed with a sexually transmitted disease such as Chlamydia, Genital Herpes, Genital Warts, Gonorrhea, HIV or AIDS? If so please explain including the date of diagnoses and form of treatment:  
Have you ever had surgery?
If so, please explain:
 
Do you have any tattoos and/or body piercings? If so, when did you receive them?  
Have you ever been incarcerated?
If so, please explain:
 
Have you ever used a mind altering drug such as marijuana, cocaine, heroin, ecstasy, LSD or methamphetamines?
If so, please explain which drug, frequency of use, and last date used:
 
Are you currently pregnant or breast feeding?
 
Have you lived outside of the United States for more than 3 months since 1980?
 
If yes, please give details on where you lived, which year(s) you lived there and for how long:
 

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