Expanding patient knowledge...
from thought to conception... and beyond
Streamlining the Gift of Life Processes...
from thought to conception... and beyond

Donor Application Form

Tell us about yourself
1. Are you eligible to work in the United States?
2. Are you a US citizen or permanent resident?
3. What is your FIRST name?
4. What is your LAST name?
5. What is your email address?
6. What is your mailing address?
Street City State/Province Zip/Postal Code Country
7. How far away from our practice do you live?
8. What is the primary phone number (include area code) to use for contact and leaving messages?
Ext.
9. What is your date of birth?
10. What is your height?
11. What is your weight?
12. What is your eye color?
13. What is your natural hair color?
14. What race would you most likely be affiliated?
Other race or self-description of race
15. Are you adopted?
16. What is the ethnic origin of your mother? (e.g. French, Irish)
17. What is the ethnic origin of your father? (e.g. French, Irish)
18. How many years of college did you complete?
19. What is your current occupation?
20. Do you have medical insurance?
21. Have you been vaccinated in the past 12 months?
If yes, what were you vaccinated for?
22. Are you currently under a physicians care for any reason?
If yes, please explain.
23. List all medications that you have taken in the proceeding 12 months (prescription). Enter "N/A" in the first box if you have not taken medications.
Rx Medications Medication How Often Reason
1
2
3
4
5
6
7
24. List all current over-the-counter medications (including hormones, vitamins, aspirin, antacids, laxatives, herbal & sports supplements, performance-enhancing supplements including steroids, etc.). Enter "N/A" in the first box if you have not taken any OTC medications.
OTC Medications Medication How Often Reason
1
2
3
4
5
6
7
25. Do you or your family or relatives have birth defects, genetic diseases, or serious medical problems?
If yes, explanation required.
26. Do you or your family or relatives have any history of any significant emotional or psychological problems (depression, bipolar, ADD, etc)?
If yes, explanation required.
27. How long is your monthly menstrual cycle (first day of one period to first day of the next)? (In days)
28. Have you ever had trouble conceiving? If yes, when and why?
If yes, when and was the cause identified?
29. How many pregnancies have you had?
30. To how many children have you given birth?
31. How many cigarettes do you smoke per day?
32. When is the last time you had marijuana?
33. When is the last time you used other recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids, or etc.)?
If yes, which one(s)?
34. Have you ever been convicted of a felony?
If yes, explanation required.
35. Does anyone in your family have a family history of alcoholism, drug use, abuse, or addiction?
If yes, please list who and additional details (such as currently struggling, in therapy, sober for 2 years, etc)
36. Have you applied or been screened to be an egg donor before?
If yes, provide the name and location of the donor program(s).
37. How many times have you donated?
38. Are you currently enrolled as an egg donor in another program?
39. Do you have other skills/hobbies/talents/interests (i.e. writing, reading, ability to do games or crossword puzzles, handcrafts)? Describe.
40. Please add additional comments or questions:
41. Are you currently pregnant or trying to get pregnant?
42. Are you currently breastfeeding?
43. What resources did you use and/or impacted your decision to apply?
Resolve American Fertility Assoc.(AFA)
Resolve LA Fertility Panit
Agency for Surrogacy Solutions Golden Egg Donation
Alternative Conceptions Graceful Conception
Alternate Family Building Growing Generations
Altruistic Angels GSMOMS
An Eggceptional Match Happy Beginnings, LLC
Angel Babies Surrogacy Heartfelt Egg Donation, LLC
Heart to Heart Donations A Perfect Match
IVF Traveler – Sue Taylor ARC Family Building
International Surrogacy Council Asian Egg Donation
Kinuko Brown Agency Baby Miracles
LA BABY Fertility Agency Baby Steps Fertility –Liz Silv
Lotus Blossom Consulting Beverly Hills Egg Donation
Loving Donation Building Families
Miracles Egg Donation Bundles of Joy
Miracle Surrogacy Center For Egg Donation Option
Modern Family Surrogacy Center Center for GC Parenting
Myrna Navas (Reproductive Solutions) Center for Surrogacy & Egg Donation
Nation Wide Egg Donation Circle Surrogacy
NightLight Christian Adoptions Coastal Surrogacy LLC
Ova the Rainbow Conceive Abilities
Open Arm Consultants Conceptional Options
Parents Via Egg Donation – Marna Conceptions
Peas in a Pod Conceptions Women’s health &…
Perfect Match Creatingbabies.com
Precious Parenting Creating New Families
Premium Egg Donation Inc Creating New Generations
Proliviti, INC Creative Conceptions
Reproductive Solutions CSP, INC
Rite Options (Contact Rita) Donor Concierge
Robert Nichols Agency Donor Egg Bank
Rocky Mountain Surrogacy LLC Donor Nexus
Sai [email protected] Donor Solution
Shelly Smith Donor Source
Single Mothers by Choice Doron Mamet-Tammuz-Inter Surrogacy
Snowflakes ED INC (Egg Donation Inc)
Steps to Family EDSI Egg Donation Surrogate Institute
Sunrise Surrogacy Solutions Egg Donation And Surrogacy Center
Surro Genesis Egg Donor Conceptions, INC
Surrogacy Dreams Egg Donation Program (Shelly Smith)
Surrogacy Solutions Egg Donor Select
Surrogate Alternatives, INC Expect Miracles Surrogacy
Surrogate Alternative Extend Fertility
Surrogate Liaisons Consulting Extraordinary Conceptions
Surrogate Parenting Services F. Williams Donor Egg Services
The Donor Egg Bank Family Creations
The Donor Source Family Journeys International
The Egg Donor Program Fertile Action
The Fertility Network Fertile Hope
The Surrogacy Program Fertility Alternatives
The Surrogacy Source Fertility Bridges
Tiny Treasures Fertility Choice
U-AHOPE (Andrew Vorzimer) Fertility Futures
USIB Fertility Miracles
West Coast Surrogacy Fertility ProRegistry
X&Y Consulting Foot Steps
Your Surrogacy Consultants Genesis Group Egg Donor
 Other
Giving Hope
Gifted Journeys – Wendie Wilson
Anaheim Corona
Baldwin Park Panorama City
Bell Flower Pasadena
Corona Riverside
Culver City San Diego
Fontana San Dimas
Glendale Tarzana
Harbor City Valencia
Hollywood West Los Angeles
Irvine Woodland Hills
Los Angeles – Sunset Kaiser Unspecified
Los Angeles Other
Long Beach Montebello
Lorie Meyers Melissa B Brisman Esq, LLC
National Fertility Law Center Steven Lazarus
Sue Shaw Fertility Law
Brookhurst/Ball Clinic Clinica de la Mujer
Clinica Medica General Gunn-Towbin Center
Magan Medical Center Maternity Clinic
Ocean View Clinic Planned Parenthood
San Miguel Medical Clinic South Indiana Physicians
TAO Wellness Center Tri-City Medical Center
Vista Family Health Center NBHC Port Hueneme
Advanced Fertility Center Chicago California Fertility Partners
Center for Coastal Conceptions Colorado Center for Reproduction
Cooper Institute of Repro NJ East Coast Infertility and IVF
Fertility Center of California Fertility Consultants
Fertility Treatment Center GIVF
La Jolla IVF Life Quest-Center for Reproductive M.
Nashville Fertility Center New England Fertility Institute
New Jersey IVF Newport Fertility Center
Northwest Reproductive Northern California Fertility
Northwest Reproductive Nova Infertility
Oregon Reproductive Medicine Pacific Connection Fertility 5
Pacific Reproductive Center Portland Center for Reproduction
Puah Center-Jerusalem Reproductive Genetics Institutes
Reproductive Medicine of New York Reproductive Medical Institute
Reproductive Partners Reproductive Science Centers
San Diego Fertility Clinic Santa Barbara Fertility
Santa Monica Fertility Southern California Reproduction
Sydney IVF Yale Fertility Center
Bay Area Genetic Counseling Gene Security Network (GSN)
Genzyme Lab Wayne State University Genetic
Cedar Sinai CHOC-Orange
City of Hope Garfield Medical Center
Glendale Adventist Glendale Memorial Hospital
Hoag Hospital Los Angeles County
Methodist Olive View
Pomona Valley Hospital Presbitarian
St. Jude Hospital Tarzana Medical Hospital
USC CF Adult Center West Los Angeles Veterans
White Memorial Hospital Womens and Children
Huntington Memorial Other
Aetna Blue Cross Website
Bluecross Insurance Bluecross/Blueshield
Cigna PPO Kaiser
Healthcare Partners Healthnet
Insurance Co Insurance Directory
Insurance –Private Healthcare Pacificare Insruance
Sharp Healthcare Tricare Insurance
United Healthcare United Health Allies
Other
Agent Egg Donation.com Online Advertisement
Angie’s List Orangecountyfertilitydr.com
Balasurrogacy.com
Oregonsurrogacycenter.com
Chat Room
Planet Hospital
Fertility Authority Popluck Club Organization
Fertility Lifelines PPC campaign
Fertility Authority Pregnancy Info.net
Fertility Network Ratemd.com
Gender_Baby.com Sart.org
Gender Dreaming SMMC
Google Top Doc LA
HRC Website (havingbabies.com) Yahoo
In Gender Yelp
Infertility.org Web MD
Infertilityspecialist.com Other
IntegraMed Internet Fertility Line
IVF Connections LocateADoc.com
Microsort Mission Hospital Website
Arroyo Seco Memorial Care Foundation
Beaver Medical Group Mission Internal
Bright Medical Monarch
Channel Island Pasadena Women’s Medical
Citrus Valley Pioneer Provider Network
Clinica San Miguel Redlands/Yucaipa
Desert Regional Medical Center SouthCoast Medical
Eastland Medical Group Talbert Medical Group
Fair Oaks Women’s Health Valley OBGYN
Harrington Benefits Other
Colleen Squires, CNP Deborah Rice, NP
Donna Roberson Julie Catron
Lori Nelson Luckie, Loriel, NOP
Samantha Vaughn, MSPA-C Other
Repromedix ReproSource
Other
Coast Magazine Conceive
Inland Empire LA Magazine
LA Opinion Newspaper Ladera Ranch
Lesbian News Magazine Magazine Advertising
New York Times Newspaper
OC Family Ad OC Register
Orange Coast Magazine Outlook Paper
Parenting OC Pasadena Magazine
Pennysaver Riviera Magazine
Verizon Directory Yellow Pages
Other
Chinese Radio 1300 AM KFI AM 640
MY FM 104.3 Persian Radio 670
Radio Ad La Mejor 96.7 Radio 98.7
Other
Drive By Office Walk In
Self Other
AIA Seminar Encino
Fullerton Pasadena
Laguna Newport
Oceanside Encino
West Lake West Los Angeles
Rancho Other
60 mins Australia Channel 11 News
Channel 34 Channel 7 ABC
Ramin Khalilli Ricki Lake
TLC- The Little Couple TV Commerical
KTLA
Other
Co-Worker Employee
Family Former Employee
Former, Prior, Patient Friend
Friend of a Friend Recipient
Sister in Law Surrogate
Word of Mouth Other
110 South Pasadena Other
No Referral Listed MD Referral – Can’t Recall Name
California Cryobank Other
Newport Beach Surgery Center Other
Chinese – Charlene S. Other

Your privacy is very important to us. Information collected here will only be shared with Reproductive Sciences Medical Center which may contact you as a follow up.