Proxy- donor application-1 person adminaccess_time September 7, 2018 Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Order Number First Name * Last Name * Maiden Name (if any) Street Address City State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Cell Phone * Home Phone Date of birth * Email * Verify email * Password for future login * Verify password * Country of birth Were you adopted? Were you adopted? Yes No How much do you weigh? Patient Weight lbs kg Describe your body type Feet Inches Patient Height Feet and Inches centimeters What is your natural hair color? What is your natural hair color? blonde black brown red/auburn gray Other Describe your hair Describe your hair wavy curly straight fine What is your natural eye color? What is your natural eye color? Black Blue Brown Gray Green Hazel Multicolored Other Describe your skin Skin Color Skin Color Albino Black Dark Yellow Dark Brown Fair Light Light Brown Medium Medium Brown Olive Ruddy Sallow Other Ethnicity Artic (Siberian, eskimo) African (Indigenous) African (American) Asian North East (Mongol, Korean, Japanese) Asian Chinese Asian Chinese Minority Groups (Tibetan, Uyghurs, Indigenous Groups in Taiwan, etc.) Asian South East (Thai, Malay, Filipino, etc.) Caucasian (European) Caucasian (Indian) Caucasian (Middle East) Caucasian (North African, Other) Indigenous Australian Native American Pacific (Polynesian, Micronesian) Hispanic Other Race Education Education High School Diploma / GED Some Trade School Trade School Certificate Currently in Community College Community College Degree Currently in College 2-Year College Degree 4-Year Bachelor’s Degree Currently in Post Baccalaureate Program Currently in Graduate Program Currently in Ph.D. Program Currently in Medical School Master’s Degree Ph.D. M.D. (Doctor of medicine) None of the above Please briefly describe your education Please briefly describe your education Please briefly describe your education What is your current marital status? What is your current marital status? single engaged married separated divorced widowed What is your occupation? What is your religious affiliation? What is your mother's ethnic origin? Artic (Siberian, eskimo) African (Indigenous) African (American) Asian North East (Mongol, Korean, Japanese) Asian Chinese Asian Chinese Minority Groups (Tibetan, Uyghurs, Indigenous Groups in Taiwan, etc.) Asian South East (Thai, Malay, Filipino, etc.) Caucasian (European) Caucasian (Indian) Caucasian (Middle East) Caucasian (North African, Other) Indigenous Australian Native American Pacific (Polynesian, Micronesian) Hispanic Other Race What is your mother's ethnic origin? What is your father's ethnic origin? Artic (Siberian, eskimo) African (Indigenous) African (American) Asian North East (Mongol, Korean, Japanese) Asian Chinese Asian Chinese Minority Groups (Tibetan, Uyghurs, Indigenous Groups in Taiwan, etc.) Asian South East (Thai, Malay, Filipino, etc.) Caucasian (European) Caucasian (Indian) Caucasian (Middle East) Caucasian (North African, Other) Indigenous Australian Native American Pacific (Polynesian, Micronesian) Hispanic Other Race What is your mother's ethnic origin? Describe your personality & character What are your special talents & interests? Do you have any health problems for which you are presently under a physicians care? Have you ever had any serious illnesses? Have you ever had any serious injuries? Have you ever had any surgical procedures or operations? Please list any medications or treatments that you take on a regular basis Do you have any allergies to medications? If yes, please list Anemia Yes No Asthma Yes No Bruising or bleeding Yes No Breast lumps Yes No Bringing up sputum Yes No Cancer Yes No Chest pain Yes No Convulsions Yes No Diabetes Yes No Discharge from nipples Yes No Dizziness/fainting Yes No Eye problems Yes No Fevers, night sweats or chills Yes No Fast or irregular heartbeat Yes No Gall bladder problems Yes No Genital sores/discharge Yes No Headaches Yes No Head injury Yes No Heart murmurs or Rheumatic fever Yes No High blood pressure Yes No Lymph nodes or glandular swelling Yes No Nosebleeds Yes No Painful or enlarged breasts Yes No Polycystic ovarian syndrome (PCO) Yes No Previous heart trouble Yes No Shortness of breath Yes No Tuberculosis (TB) or exposure to TB Yes No Thyroid disease Yes No Trouble thinking or remembering Yes No Yellow jaundice or hepatitis Yes No Seizures Yes No Abnormal Pap Yes No Please describe any problems checked above Do you drink alcohol? If yes, how much per week? Do you use marijuana? If yes, how much per week? Do you smoke? If yes, how much per week? Have you ever used illegal drugs? If yes, please describe. Have you ever received a blood transfusion? If yes, please explain Have you ever been pregnant? Yes No If yes, how many times? Please list the year(s) that you were pregnant and the outcome(s) of the pregnancy: Year Outcome (delivered pregnancy, miscarriage, abortion, etc.) Year Outcome (delivered pregnancy, miscarriage, abortion, etc.) Year Outcome (delivered pregnancy, miscarriage, abortion, etc.) Year Outcome (delivered pregnancy, miscarriage, abortion, etc.) Have you ever been treated for any major women's health or gynocology problems? If yes, please list AIDS aids Myself Partner Neither Gonorrhea Gonorrhea Myself Partner Neither Hepatitis B Hepatitis B Myself Partner Neither Hepatitis C Hepatitis C Myself Partner Neither Herpes Herpes Myself Partner Neither HIV HIV Myself Partner Neither HPV HPV Myself Partner Neither Syphilis Syphilis Myself Partner Neither Trichomoniasis Trichomoniasis Myself Partner Neither Are you using contraception for birth control? If yes, what method? Have you ever been treated for psychiatric disorders? If yes, please explain: Do you have any learning disabilities? If yes, please explain: Please list any additional health information which may be important Blood Type (i.e. A+ or B Negative) Have you ever had an abnormal pap? Do you receive a regular, monthly period? Are your cycles regular when not on birth control? How many days are between the start of one period to your next? Do you have any piercings or tattoos? If yes when was the most recent one? Have you traveled to the Caribbean, South America, Southern Florida, or any Zika Virus Infected Area in the past 6 moths? If so, when and where? Have you traveled to Malarial Infected Areas in th past 6 months? If so, when and where? How often do you exercise? Are you prescribed glasses or contact lenses? What is your dominant hand? Height Height Feet & Inches centimeters Weight Weight LBS Kilograms Hair Color Eye Color Complexion Mother Feet Inches Weight Hair Color Hair Color Blonde Black Brown Red/auburn Gray Eye Color Complexion Complexion Fair Olive Dark Father Feet Inches Weight Hair Color Hair Color Blonde Black Brown Red/auburn Gray Eye Color Complexion Complexion Fair Olive Dark Maternal Grandmother Feet Inches Weight Education Level Education Level High School Some College College Degree Graduate Degree Hair Color Hair Color Blonde Black Brown Red/auburn Gray Eye Color Complexion Complexion Fair Olive Dark Maternal Grandfather Feet Inches Weight Education Level Education Level High School Some College College Degree Graduate Degree Hair Color Hair Color Blonde Black Brown Red/auburn Gray Eye Color Complexion Complexion Fair Olive Dark Paternal Grandmother Feet Inches Weight Education Level Education Level High School Some College College Degree Graduate Degree Hair Color Hair Color Blonde Black Brown Red/auburn Gray Eye Color Complexion Complexion Fair Olive Dark Paternal Grandfather Feet Inches Weight Education Level Education Level High School Some College College Degree Graduate Degree Hair Color Hair Color Blonde Black Brown Red/auburn Gray Eye Color Complexion Complexion Fair Olive Dark Sister #1 Feet Inches Weight Education Level Education Level High School Some College College Degree Graduate Degree Hair Color Hair Color Blonde Black Brown Red/auburn Gray Eye Color Complexion Complexion Fair Olive Dark Sister #2 Feet Inches Weight Education Level Education Level High School Some College College Degree Graduate Degree Hair Color Hair Color Blonde Black Brown Red/auburn Gray Eye Color Complexion Complexion Fair Olive Dark Sister #3 Feet Inches Weight Education Level Education Level High School Some College College Degree Graduate Degree Hair Color Hair Color Blonde Black Brown Red/auburn Gray Eye Color Complexion Complexion Fair Olive Dark Sister #4 Feet Inches Weight Education Level Education Level High School Some College College Degree Graduate Degree Hair Color Hair Color Blonde Black Brown Red/auburn Gray Eye Color Complexion Complexion Fair Olive Dark Brother #1 Feet Inches Weight Education Level Education Level High School Some College College Degree Graduate Degree Hair Color Hair Color Blonde Black Brown Red/auburn Gray Eye Color Complexion Complexion Fair Olive Dark Brother #2 Feet Inches Weight Education Level Education Level High School Some College College Degree Graduate Degree Hair Color Hair Color Blonde Black Brown Red/auburn Gray Eye Color Complexion Complexion Fair Olive Dark Brother #3 Feet Inches Weight Education Level Education Level High School Some College College Degree Graduate Degree Hair Color Hair Color Blonde Black Brown Red/auburn Gray Eye Color Complexion Complexion Fair Olive Dark Brother #4 Feet Inches Weight Education Level Education Level High School Some College College Degree Graduate Degree Hair Color Hair Color Blonde Black Brown Red/auburn Gray Eye Color Complexion Complexion Fair Olive Dark Ethnic Background: Please list the ethnic extractions (if known) of your grandparents Maternal grandmother Material grandfather Paternal grandmother Paternal grandfather Maternal grandmother Ethnic 1 Ethnic Background: Maternal grandmother 1 Material grandfather Ethnic 1 Ethnic Background: Material grandfather 1 Paternal grandmother Ethnic 1 Ethnic Background: Paternal grandmother 1 Paternal grandfather Ethnic 1 Ethnic Background: Paternal grandfather 1 Maternal grandmother Ethnic 2 Ethnic Background: Maternal grandmother 2 Material grandfather Ethnic 2 Ethnic Background: Material grandfather 2 Paternal grandmother Ethnic 2 Ethnic Background: Paternal grandmother 2 Paternal grandfather Ethnic 2 Ethnic Background: Paternal grandfather 2 Maternal grandmother Ethnic 3 Ethnic Background: Maternal grandmother 3 Material grandfather Ethnic 3 Ethnic Background: Material grandfather 3 Paternal grandmother Ethnic 3 Ethnic Background: Paternal grandmother 3 Paternal grandfather Ethnic 3 Ethnic Background: Paternal grandfather 3 Maternal grandmother Ethnic 4 Ethnic Background: Maternal grandmother 4 Material grandfather Ethnic 4 Ethnic Background: Material grandfather 4 Paternal grandmother Ethnic 4 Ethnic Background: Paternal grandmother 4 Paternal grandfather Ethnic 4 Ethnic Background: Paternal grandfather 4 List any health problems (make your best estimates of ages, etc: if no health problems enter "none") : Mother Age Mother's Age Living/Deceased Living Deceased Mother Living/Deceased List any health problems Mother: List any health problems Father Age Father's Age Living/Deceased Living Deceased Father Living/Deceased List any health problems Father: List any health problems Maternal Grandmother Age Maternal Grandmother's Age Living/Deceased Living Deceased Maternal Grandmother Living/Deceased List any health problems Maternal Grandmother: List any health problems Maternal Grandfather Age Maternal Grandfather's Age Living/Deceased Living Deceased Maternal Grandfather Living/Deceased List any health problems Maternal Grandfather: List any health problems Paternal Grandmother Age Paternal Grandmother's Age Living/Deceased Living Deceased Paternal Grandmother Living/Deceased List any health problems Paternal Grandmother: List any health problems Paternal Grandfather Age Paternal Grandfather's Age Living/Deceased Living Deceased Paternal Grandfather Living/Deceased List any health problems Paternal Grandfather: List any health problems Sister #1 Age Sister #1 Age Living/Deceased Living Deceased Sister #1 Living/Deceased List any health problems Sister #1: List any health problems Sister #2 Age Sister #2 Age Living/Deceased Living Deceased Sister #2 Living/Deceased List any health problems Sister #2: List any health problems Sister #3 Age Sister #3 Age Living/Deceased Living Deceased Sister #3 Living/Deceased List any health problems Sister #3: List any health problems Sister #4 Age Sister #4 Age Living/Deceased Living Deceased Sister #4 Living/Deceased List any health problems Sister #4: List any health problems Brother #1 Age Brother #1 Age Living/Deceased Living Deceased Brother #1 Living/Deceased List any health problems Brother #1: List any health problems Brother #2 Age Brother #2 Age Living/Deceased Living Deceased Brother #2 Living/Deceased List any health problems Brother #2: List any health problems Brother #3 Age Brother #3 Age Living/Deceased Living Deceased Brother #3 Living/Deceased List any health problems Brother #3: List any health problems Brother #4 Age Brother #4 Age Living/Deceased Living Deceased Brother #4 Living/Deceased List any health problems Brother #4: List any health problems Please explain any positive findings from the list above Is there anyone in your family that suffers from a substance abuse problem (alcoholism, drug abuse)? Is there anyone in your family that suffers from severe psychiatric disorders (major depression, schizophrenia, manic depressive disease? Is there anyone in your family that suffers from infertility? Is there anyone in your family that suffers from repeated miscarriage (three or more miscarriages)? Have you or anyone in your family had a baby with birth defects? Has anyone in your famiily gone through early menopause (before the age of 45)? Describe any known inherited diseases or genetic diseases, such as cystic fibrosis, hemophilia, Tay-Sachs disease, or Fragile X syndrome in your family? Certain inherited diseases or genetic diseases are more common in certain ethnic and/or religious groups. Please check if you are of the following ancestry MediterraneanAncestry Mediterranean (Greek or Italian) Jewish African Alzheimer's Alzheimer's None Mother Father Brother Sister Grandparent Anorexia/bulimia Anorexia/bulimia None Mother Father Brother Sister Grandparent Arthritis Arthritis None Mother Father Brother Sister Grandparent Asthma Asthma None Mother Father Brother Sister Grandparent Blood disorders Blood disorders None Mother Father Brother Sister Grandparent Cancer Cancer None Mother Father Brother Sister Grandparent Cleft lip and/or palate Cleft lip and/or palate None Mother Father Brother Sister Grandparent Congenital heart defects Congenital heart defects None Mother Father Brother Sister Grandparent Cystic fibrosis Cystic fibrosis None Mother Father Brother Sister Grandparent Depression Depression None Mother Father Brother Sister Grandparent Diabetes Diabetes None Mother Father Brother Sister Grandparent Early death Early death None Mother Father Brother Sister Grandparent Gall bladder disease Gall bladder disease None Mother Father Brother Sister Grandparent Heart attack Heart attack None Mother Father Brother Sister Grandparent Huntington's disease Huntington's disease None Mother Father Brother Sister Grandparent Lupus Lupus None Mother Father Brother Sister Grandparent Manic depression Manic depression None Mother Father Brother Sister Grandparent Mental retardation Mental retardation None Mother Father Brother Sister Grandparent Muscular dystrophy Muscular dystrophy None Mother Father Brother Sister Grandparent Nearofibromatosis Nearofibromatosis None Mother Father Brother Sister Grandparent Obesity Obesity None Mother Father Brother Sister Grandparent "Open spine" (spinabifida) Open spine (spinabifida) None Mother Father Brother Sister Grandparent Parkinsons's disease Parkinsons's disease None Mother Father Brother Sister Grandparent Polycystic kidney disease Polycystic kidney disease None Mother Father Brother Sister Grandparent Polycystic ovarian syndrome (PCO) Polycystic ovarian syndrome (PCO) None Mother Father Brother Sister Grandparent Premature senility Premature senility None Mother Father Brother Sister Grandparent Progressive kidney disease Progressive kidney disease None Mother Father Brother Sister Grandparent Serious birth defects Serious birth defects None Mother Father Brother Sister Grandparent Severe bleeding tendency Severe bleeding tendency None Mother Father Brother Sister Grandparent Stroke Stroke None Mother Father Brother Sister Grandparent Two or more miscarriages or stillbirths Two or more miscarriages or stillbirths None Mother Father Brother Sister Grandparent Last Questions Why do you desire to be an egg donor? What message would you like to send to the recipients of your egg donation? Have you applied or been screened to be an egg donor before? Yes No Have you donated before? Yes No if yes, how many times did you donate or cycle? Are you currently enrolled as an egg or sperm donor in another program? Yes No Do you currently have health care coverage? Yes No Emergency Contact Name Emergency Contact Relation Emergency Contact Phone High School Graduation Year GPA What Degrees do you hold? College/University College Major Graduation Year Degree Acquired GPA SAT Score ACT Score Have you won any awards or scholarships? Yes No Do you have any athletic abilities? (i.e. played volleyball for 4 years, etc.) Do you have any artistic abilities or did you play any instruments? What would you say is your biggest accomplishment in life thus far? How would your friends describe your personality? What is your favorite color? What is your favorite food? What is your dream vacation? What is your fondest memory? What are your goals and aspirations? Do you know any other languages? Have you ever been convicted of a crime? Have you ever been convicted of a crime? Yes No Have you ever been arrested, including a DUI arrest? Have you ever been arrested, including a DUI arrest? Yes No Do you currently have any legal cases or claims pending? Do you currently have any legal cases or claims pending? Yes No Has there been a restraining order filed against you in the past 5 years? Has there been a restraining order filed against you in the past 5 years? Yes No Have you filed a restraining order against someone in the past 5 years? Have you filed a restraining order against someone in the past 5 years? Yes No Have you ever filed for divorce or legal separation? Have you ever filed for divorce or legal separation? Yes No Have you ever been past due on child support? Have you ever been past due on child support? Yes No Have you ever been arrested or convicted of a felony? Have you ever been arrested or convicted of a felony? Yes No If yes, please explain: Inportant Note: To help protect your identity, DO NOT INCLUDE photos that are also on social media sites and/or publicly available. Certain search engines may maybe able to match your photo with your identity. This service takes significant measures to protect your identity, but there are several resources beyond our control, and requires your comeration to limit the risk. Upload Process Click "Choose Photo" Select a photo & click "Submit Application" to upload & save. Photo Requirements Photo must be in .jpg/.jpeg/.png/.gif format Convert to jpg using this online tool Must be less than 5MB in size If scanning photos, choose low resolution Photo Recommandations Use the free online photo adjustment service No Collages Rotate photo to be upright Crop photo to focus on you not background Upload a face photo donor_image Photo group Photo group Photo group
