Donor Application

 

First Name:
 
Last Name:
 
Mailing Address:
 
City:
 
State:
Zip Code:
 
What is the closest major city to where you live?
 
Email Address:
   
Verify 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:
     
Age:
 
Ethnicity:
 
Height:
' "  
Weight:
 
Natural Hair Color:
 
Hair Color as a Child:
 
Eye color:
Do you smoke?
 
Have you smoked Cigarettes in the past 3 months?
 
Are you willing to take a nicotine screening test?
 
Do you drink, if so how often?
 
Are you adopted?
 
If so, will you be able to provide any health history for at least one side of your biological family?
 
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?

 
Would you be willing to submit copies of your college transcripts if requested
 
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?
 
Are you presently using the birth control Depo Prevera (the shot) or have you used Depo Prevera in the past 12 months?
 
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:
 
I understand that a current pap (within 12 months) is required and that Family Creations will be asking to receive a copy of my most recent pap.
  Click this check box if you agree to send Family Creations a copy of your recent pap.
Have your or your partner tested positive for Chlamydia in the past 12 months?
 
Have your or your partner tested positive for Gonorrhea in the past 12 months?
 
Have your or your partner tested positive for Syphilis in the past 12 months?
 
Have you or your partner tested positive for HIV/AIDS?
 
Please clarify your previous response


 
Have you ever had surgery?
If so, please explain:
 
Have you ever been incarcerated?
 
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:
 
Have you used any illegal drugs in the past 12 months?
 
Are you willing to take a drug test?
 
Are you currently pregnant or breast feeding?
 
Have you traveled to a country in the past 12 months where you were advised / required to receive a malaria vaccine?
 
Have you traveled to Iraq in the past 12 months?
 
Have you lived in any of the following countries for 5 or more consecutive years?
Albania, Austria, Belgium, Bosnia / Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Kosovo (Federal Republic of Yugoslavia), Liechtenstein, Luxembourg, Macedonia, Montenegro (Federal Republic of Yugoslavia), Netherlands (Holland), Norway, Poland Portugal, Romania, Serbia (Federal Republic of Yugoslavia), Slovak Republic (Slovakia), Slovenia, Spain, Sweden, Switzerland, Turkey, Yugoslavia (Federal Republic includes Kosovo, Montenegro, and Serbia)
 
Have you lived in or visited any of the following countries for 3 or more months between 1980 and 1996?
Channel Islands, England, Falkland Islands, Gibraltar, Isle of Man, Northern Ireland, Scotland or Wales
 
Have you received a tattoo in the past 12 months?
 
Have you received a piercing in the past 12 months?
 
Are you or any of your biological family members registered with any Native American tribes?
 
Are you currently enlisted in the Military?
 
Please upload a recent photograph of yourself. Applications with photographs submitted will be processed faster.
 
I represent that all written representations and information provided and/or to be provided to Family Creations, LLC, and any professional, psychologist, physician, physician's assistant, nurse, attorney, or designee of Family Creations, are true, correct and complete.
Click this check box if you agree