Egg Donor Application

"*" indicates required fields

1Basic Information

2Health History

3Medical History

4Personal History

5Confirmation

Tell Us About Yourself

First Name*

Last Name*

Mailing Address*

City*

State*

Zip Code*

What is the closest major city to where you live?*

Email*

Enter Email Confirm Email

Best Contact Phone Number:*

Message OK?

Yes

Second Contact Phone Number:

Message OK?

Yes

Date of Birth:*

MM slash DD slash YYYY

Age*

Ethnicity*

Mark all that apply

African American

Asian

Black

Caucasian

Cuban

Hispanic

Indian

Jewish

Mien

Middle Eastern

Native American

South American

Southeast Asian

White

Other

Ethnicity Other*

Height Feet*

Please enter a number less than or equal to 12.

Height Inch*

Please enter a number less than or equal to 12.

Weight*

Please enter in pounds

BMI*

Please enter in pounds

Natural Hair Color:

Hair Color as a Child:

Eye Color:

How did you hear about us?*

Friend/Family First Name

Friend/Family Last Name

Have you completed high school?*

Yes

Are you currently a college student?

Yes

Do you have a college degree?

Yes

What is your major/degree?

Would you be willing to submit copies of your college transcripts if requested?

Yes

Does Not Apply

Tell Us About Your Health History

Do you smoke?*

Yes

Have you smoked cigarettes in the past 3 months?*

Yes

Do you drink? If so how often?*

Are you adopted?*

Yes

Are you employed?*

Yes

Occupation:

Number of Siblings:*

Marital Status:*

Spouse First Name*

Spouse Last Name*

Spouse Email*

Tell Us About Your Medical History

Number of sexual partners in the last year:*

Number of sexual partners in your lifetime:*

Have you been an egg donor before?*

Yes

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?*

Yes

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?*

Yes

Have your or your partner tested positive for Gonorrhea in the past 12 months?*

Yes

Have your or your partner tested positive for Syphilis in the past 12 months?*

Yes

Have you or your partner tested positive for HIV/AIDS?*

Yes

Have you ever been incarcerated?*

Yes

Have you ever had surgery? If so, please explain:*

Tell Us About Your Personal History

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?*

Yes

Are you currently pregnant or breast feeding?*

Yes

Have you traveled to a country in the past 12 months where you were advised / required to receive a malaria vaccine?*

Yes

Have you traveled to Iraq in the past 12 months?*

Yes

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)

Yes

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

Yes

Have you received a tattoo in the past 12 months?*

Yes

Have you received a piercing in the past 12 months?*

Yes

Are you or any of your biological family members registered with any Native American tribes?*

Yes

Are you currently enlisted in the military?*

Yes

Please upload a recent photograph of yourself. Applications with photographs submitted will be processed faster.

Accepted file types: jpg, jpeg, png, gif.

Confirm Your Application*

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.

I agree

Confirmation

Thank you for your interest in Family Creations. Please create a password. You will use this password to login to your account, update your profile and submit required documentation

Password

Enter Password Confirm Password

Submit an Egg Donor Application to Give the Gift of Life