Egg Donor Application | Apply to Become an Egg Donor

Egg Donor Questionnaire

Applying to NAFG’s egg donation program is convenient, secure, and confidential. The Egg Donor Application may be submitted electronically by clicking below. The information you submit will be accessible to our egg donor coordinator only.

This application takes approximately 20-30 minutes to fill out.

This application is for pre-screening only. By submitting an application, you are not committing to be an egg donor, and does not necessarily guarantee you admission to our program.

Once you submit your application, you will receive an automatic e-mail acknowledgement. If we can take action on your application, our coordinator will contact you by e-mail within two days.

Because of the high number of applications we receive, we can only respond to a small percentage of applicants. If we cannot take action on your questionnaire, your information will be deleted securely.

Your application is not complete without current digital photos; please send the clearest ones you have for your initial application.

Digital photos should be sent to inquiry@assistedfertility.com

Basic Information

First Name*

Last Name*

Date of Birth*

Address

Address*

Address 2

City*

State*

Zip*

Email Address*

Phone Number*

Can we text you and leave voicemails at this number?*

Yes No

Emergency Contact

Emergency Contact Name

Emergency Contact Phone

Do you have a social security number?

Yes No

Occupation

Work Address

Are you a US citizen?

Yes No

If not, please describe your status.

Marital Status*

Date of marriage or length of relationship

Husband / Partner's Name

Husband / Partner's Occupation

Husband / Partner's Date of Birth

Have you donated eggs before?

Yes No

If yes, please provide dates and location(s)/facility(ies) of donation(s), the doctor's name(s) and contact information.

Medical/Physical History

Are you currently taking any medications or do you have any illnesses or conditions?

Yes No

If yes, please specify.

If you had any illnesses or were prescribed any drugs in the past five years, please specify.

Do you see a gynecologist regularly?

Yes No

Do you have regular menstrual periods?

Yes No

What is the typical duration of your cycle (number of days in between periods)?

Are you currently using birth control?

Yes No

If yes, please specify the method.

Have you ever had an abnormal pap smear?

Yes No

If yes, please provide date(s) and treatment.

Have you ever been pregnant?

Yes No

Have you or any of your partners ever had a sexually transmitted disease?

Yes No

If yes, please provide date(s) and information.

Have you or any of your partners received a blood transfusion?

Yes No

If yes, please provide date(s) and information.

Have you or any of your partners received a body piercing or tattoo?

Yes No

If yes, please provide date(s) and information.

Do you smoke?

Yes No

If yes, how much?

Do you drink alcoholic beverages?

Yes No

If yes, please specify how often.

Have you ever been exposed to radiation, toxic chemicals, lead, asbestos, insecticides, and/or cleaning solutions at your job or elsewhere?

Yes No

Have you ever received pituitary-derived human growth hormone?

Yes No

Do you take any recreational drugs?

Yes No

If yes, please specify.

How many sexual partners have you had in the past six months?

Have you ever been treated by a psychologist or a psychiatrist?

Yes No

If yes, please list the dates, descriptions, and locations of any surgeries and/or hospitalizations.

Have you ever been arrested or convicted of a crime?

Yes No

If yes, specify and provide dates.

Personal Information

Please describe, to the best of your ability, your ethnic background.

What religion were you born into?

What religion do you practice now?

Where were you born?

Where did you grow up?

How many brothers and sisters do you have?

Mother's Ethnicity

Father's Ethnicity

List any particular physical characteristics that run in your family (such as curly hair, tall, freckles, etc.)

Current Weight

Height

Has your weight ever increased or decreased drastically? If so, please explain.

Shoe Size

Body Frame

What is your eye color?

Do you wear glasses or contacts?

Yes No

If yes, at what age did you begin and why do you need them?

Have you ever worn braces?

Yes No

If yes, for how long?

Are your teeth in good health?

Yes No

Do you see a dentist regularly?

Yes No

Please describe your current diet and exercise routine.

Please list any vitamin or herbal supplements that you take regularly.

Do you have any special talents or abilities in music, art, athletics, languages, or any other field? If so, please describe.

Please list the dates and locations of all your academic degrees, starting with high school.

Did you receive any academic honors or awards, or excel in any particular subject in school? Were you a member of any clubs or athletic teams? If so, please describe.

Please indicate the dates and scores of your standardized tests, which may include the SAT, ACT, LSAT, GRE, etc. Please specify quantitative and verbal scores where applicable.

Please list your job titles and places of employment, starting from your present job.

Please list the foreign countries you have visited, and the dates of your travel.

To the best of your ability, describe your personality.

Please describe your interests and favorite activities.

Why do you want to be an egg donor?

Do you have any preferences regarding the race, religion, marital status, or sexual orientation of the possible recipient of your eggs?

Have you informed your family, friends, and others close to you about your interest in egg donation? Do you plan to inform them? If so, do you think they will be supportive of your decision?

Is there anything else you would like possible egg recipients to know about you?

Immediate Family

Mother

Age, if Living

Cause/Age of death

Father

Age, if Living

Cause/Age of death

Maternal Grandmother

Age, if Living

Cause/Age of death

Maternal Grandfather

Age, if Living

Cause/Age of death

Paternal Grandmother

Age, if Living

Cause/Age of death

Paternal Grandfather

Age, if Living

Cause/Age of death

Your Child (1)

Age, if Living

Cause/Age of death

Your Child (2)

Age, if Living

Cause/Age of death

Your Sibling (1)

Age, if Living

Cause/Age of death

Your Sibling (2)

Age, if Living

Cause/Age of death

Your Sibling (3)

Age, if Living

Cause/Age of death

Your Sibling (4)

Age, if Living

Cause/Age of death

Family Medical History

Please indicate any of the following conditions that you have:

Consent

I verify that the information on this application is complete and accurate. I understand that any false statement made by me may be viewed as perjury and in violation of the penal laws of my state and may subject me to criminal and/or civil penalties.*

I here by authorize NAFG to use this information as part of an anonymous profile to submit to prospective recipients and medical professionals for evaluation. This anonymous profile may be presented in written (hard copy) or electronic form to prospective recipients and medical professionals at the discretion of NAFG in its efforts to make an appropriate match. My profile will remain anonymous unless and until I submit prior written consent. I here by authorize NAFG to use my photograph(s) on its Web site as part of my anonymous profile. This profile will be viewed by registered NAFG users only.*

To: NAFG and any of its affiliates, including but not limited to medical doctors and personnel, medical facilities, mental health professionals, social workers, and attorneys: I authorize NAFG to conduct any necessary background checks, including but not limited to criminal, financial, and medical records, pertaining to me. I acknowledge that other interested parties, including but not limited to intended parents, attorneys, medical personnel, etc., will rely on this information. I understand that any false statement made by me may be viewed as perjury and in violation of the penal laws of my state and may subject me to criminal and/or civil penalties. This authorization shall remain valid for two years from the date thereof. A copy shall have the same force as the original.*

Egg Donor Questionnaire

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