First Name *

Last Name *

Email Address (please provide a personal email address not a school or work email) *

Confirm Email Address *

Password *

Confirm Password *

Address *

City *

State *

Postal Code *

Country *

-- Select country -- AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegowinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCote d-IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea-NorthKorea-SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania, United Republic ofThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaVietnamWallis and Futuna IslandsWestern SaharaYemenYugoslaviaZambiaZimbabwe

Nearest major city to you (if you don't live in a major city) and the distance away. *

Cell Phone *

Home Phone

Your Age Today *

Birth Date *

Where did you learn about Fertility Heaven? *

Have you ever donated your eggs before? *

Yes

No

List below the dates you donated and the results of each of your egg donations (# eggs retrieved, # of embryos made, # of embryos frozen, pregnancy result, birth result).

What is your current status? *

Available Now
On hold for intended parents
In donation cycle treatment
Repeat Donor

Please select the lowest egg donation fee you are willing to accept. *

Would you like to be anonymous to recipients? *

Yes
No
Not Sure

Are you willing to report any new health issues that you may have in the future to the attorney of the recipients? Your anonymity will be maintained. *

Yes
No
Not Sure

Have you ever been convicted of a crime? *

Yes

No

Are you adopted and unable to provide your full genetic history? *

Yes

No

Have you used antidepressants within the last year? *

Yes

No

Have you smoked tobacco within the last year? *

Yes

No

What kind of birth control are you using? *

Have you ever had an abnormal pap smear? *

Yes

No

Have you ever seen a doctor in the past year for any reason? *

Yes

No

Have you ever been hospitalized for substance abuse, depression, or any other psychological problem? *

Yes

No

Does your family have any history of cancer or heart disease under the age of 55? *

Yes

No

Have you ever been diagnosed with any gynecological issues such as fibroids, ovarian cysts, endometriosis, PID (Pelvic inflammatory disease)? *

Yes

No

Has anyone in your family had fertility problems? *

Yes

No

Has your mother or sister had menstrual, ovarian or uterine problems? *

Yes

No

College Education. *

CC: Enrolled in College Classes
AA: Completed Associate Degree
GD: Completed Graduate Degree
BA: Completed Bachelor's Degree
Other

Please list the college and degree you are pursuing and have achieved. *

What is your college GPA for each degree you have pursued? *

Check the tests you have taken. *

ACT
SAT
IQ
Other

Did you graduate from High School? *

Yes

No

Did you have any learning disabilities? *

Yes

No

Height *

Please select the closest weight. *

Eye Color *

Blue
Green
Hazel
Brown

Hair Color (Natural hair color) *

Hair Type *

Complexion *

What is your blood type? *

Have you had plastic surgery? *

Yes

No

What is your race? *

What ethnic groups do you belong to? Please check those that are significant. *

What activities would you consider yourself accomplished in? *

Artist
Athlete
Dancer
Musician
Singer

What are your hobbies? List below, separated by commas. *

Have you given birth to children? *

Yes

No

Relationship Status

Name of your emergency contact person? By providing their name here, you give us permission to contact them prior to your cycle and confirm it is a working phone number and verify their relationship to you.

Relationship to you of emergency contact person.

Emergency Contact Cell Phone

Emergency Contact Email Address

Are you currently employed?

Yes

No

What is your vision?

Have you had surgery to correct your vision?

Yes

No

Did you have braces?

Yes

No

Have you been treated for Zika?

Yes

No

How is your hearing?

What is your sexual orientation?

Do you have health insurance?

Yes

No

How many glasses of alcohol do you drink per week on average?

0
1-3
4-6
7-10
>10

Do you take any drugs or prescription drugs?

Yes

No

Please check if you have used any of the following. Many clinics require drug testing before you will be qualified to donate.

Have you had any of the following?

Tattoos
Body Piercing
Acupuncture
Blood Transfusions
None of the above

Please list the dates and describe each of the above that you have checked.

Please check below any STD's you and/or your partner have been diagnosed with.

List any illnesses that have lasted longer than a week and describe what happened.

Please list any hospitalizations, operations or surgeries you have had and the date.

Have you, or any family member, ever been under the care of a psychiatrist?

Yes

No

Have you, or any family member, ever received treatment for drug and/or alcohol abuse?

Yes

No

Have you had counseling or psychotherapy?

Yes

No

Are there any medical conditions for which you are currently being seen or treated?

Yes

No

When was your last pap smear and what were the results?

What was the age of your first menstrual period?

Are your menstrual cycles regular?

Yes
No
Sometimes
Other

How many days does your period last?

Have you ever been pregnant?

Yes

No

Have you ever had a miscarriage?

Yes

No

Have you ever had an abortion?

Yes

No

Do you have children?

Yes

No

Do you have an incidence of twins in your family.

Yes

No

Mother's Age:

Birth date :

Ethnicity:

Height :

Eye Color :

Blue
Green
Hazel
Brown

Hair Color (as a child) :

Blond
Red
Light Brown
Brown
Black

Hair Type :

Straight
Wavy
Curly
Fine
Course

Complexion :

Weight :

Slender
Average
Overweight by 20 pounds
Overweight by 40 pounds or more

Vision (when younger than 40 years old) :

Perfect vision
Needed glasses/contacts sometimes
Needed glasses/contacts all the time

General Health :

Excellent health
Good health
Occasionally has health issues
Dealing with health issues consistently
Has a major illness

Describe any health issues. If mother passed away please list date and reason.:

Did your mother have any miscarriages?

Yes

No

How many miscarriages did she have?

Profession:

Personality/Talents:

Father's Age:

Birth date :

Ethnicity:

Height :

Eye Color :

Blue
Green
Hazel
Brown

Hair Color (as a child) :

Blond
Red
Light Brown
Brown
Black

Hair Type :

Straight
Wavy
Curly
Fine
Course

Complexion :

Light
Fair
Medium
Olive
Brown
Black

Weight :

Slender
Average
Overweight by 20 pounds
Overweight by 40 pounds or more

Vision (when younger than 40 years old) :

Perfect vision
Needed glasses/contacts sometimes
Needed glasses/contacts all the time

General Health :

Excellent health
Good health
Occasionally has health issues
Dealing with health issues consistently
Has a major illness

Profession:

Personality/Talents:

Sibling 1 Age:

Birth date:

Gender:

Height :

Eye Color :

Blue
Green
Hazel
Brown

Hair Color (as a child) :

Blond
Red
Light Brown
Brown
Black

Hair Type :

Straight
Wavy
Curly
Fine
Course

Complexion :

Weight :

Slender
Average
Overweight by 20 pounds
Overweight by 40 pounds or more

Vision :

Perfect vision
Needed glasses/contacts sometimes
Needed glasses/contacts all the time

General Health :

Excellent health
Good health
Occasionally has health issues
Dealing with health issues consistently
Has a major illness

Education:

Profession:

Sibling 2 Age:

Birth date :

Gender:

Height :

Eye Color :

Blue
Green
Hazel
Brown

Hair Color (as a child) :

Blond
Red
Light Brown
Brown
Black

Hair Type :

Straight
Wavy
Curly
Fine
Course

Complexion :

Weight :

Slender
Average
Overweight by 20 pounds
Overweight by 40 pounds or more

Vision :

Perfect vision
Needed glasses/contacts sometimes
Needed glasses/contacts all the time

General Health :

Excellent health
Good health
Occasionally has health issues
Dealing with health issues consistently
Has a major illness

Education:

Profession:

Please list all other full and half siblings here and cover the same questions you did for your first 2 siblings. However you can describe them in paragragh form:

Grandmother's Age (Mother's side):

Ethnicity:

List grandmother's characteristics: eye color, hair color, height, weight, and complexion.:

Describe your grandmother's health issues she experienced during her life. If she passed away, please provide her age at death and what she died from:

Grandfather's Age (Mother's Side):

Ethnicity:

List grandfather's characteristics: eye color, hair color, height, weight, and complexion:

Describe your grandfather's health issues he experienced during his life. If he passed away, please provide his age at death and what he died from:

Grandmother's Age (Father's Side):

Ethnicity:

List Grandmother's characteristics: eye color, hair color, height, weight, and complexion:

Describe your grandmother's health issues she experienced during her life. If she passed away, please provide her age at death and what she died from:

Grandfather's Age (Father's Side):

Ethnicity:

List grandfather's characteristics: eye color, hair color, height, weight, and complexion:

Describe your grandfather's health issues he experienced during his life. If he passed away, please provide his age at death and what he died from:

Please check if your parents, grandparents, aunts, uncles, first cousins or any family member has had the following conditions. Most donors have at least 5 health conditions (some many more), so be sure to list everything after you have talked to your family :

For each item you checked above, write the name of the health disorder and the name of the person in your family who has or had it and their relation to you.

What are your special talents and skills?

How would your friends describe you?

What has been your favorite vacation and why?

What is your favorite childhood memory with your family, school or friends?

What has been your biggest personal or professional achievement?

What are your favorite activities to do in your free time?

What are your favorite foods?

I understand that the photos (and the other information) I provide through this application will be made available online for intended parents who are looking for egg donors and for third parties who are searching our online database for donors for their clients. Photos are required to be part of the Fertility Heaven database.

Yes, I understand how my photos will be used.
Yes, I understand how my photos will be used and choose not to upload them, which means I will not be accepted as a donor applicant unless I make special arrangement with Fertility Heaven

Main profile photo.

Upload an Image

Your 2nd photo should be a recent picture that includes your whole body.

Upload an Image

Your 3rd photo should be your favorite taken any time in your life.

Upload an Image

Your 4th photo should be you doing something you love, such as a sport or other activity.

Upload an Image

Your 5th photo is your choice.

Upload an Image

Your 6th photo is your choice and should be very clear, focused, well lit and show your sparkling personality.

Upload an Image

Your 7th photo should be you with your family members. Recipients are typically looking for a resemblence either with your or your family members since they carry the same genetics.

Upload an Image

Your 8th photo should be of you as a baby.

Upload an Image

Your 9th photo should be of you as a toddler (age 2-3).

Upload an Image

Your 10th photo should be you between ages 4-10.

Upload an Image

Upload Info Video

I certify that the information I provide on my Fertility Heaven profile page accurately reflects my background, academic achievements, medical history, as well as my personal characteristics. I understand that I could be subject to civil or criminal charges if I purposely fraudulently misrepresent myself or purposely leave out important and relevant information about my background, lifestyle choices, drug use (drug testing may be required by the fertility clinic) or health and genetic history of myself or my immediate family members which includes parents, siblings, grand parents, aunts, uncles and cousins, which must be ascertained to determine if I am a good genetic candidate for egg donation. I understand that the fertility clinic may run genetic testing on me to determine any genetic issues. I could also be responsible for any expenses related to my background check, verification of my records, travel, legal and medical expenses in relation to my egg donation cycle, or other expenses if fraud is proved.

Yes, I certify my information is correct.
No, my information is not correct.

I have answered all the questions in both Phase I and Phase II above and would like to submit my application to become an egg donor with the Fertility Heaven Egg Donation Program. If I am approved my profile with be entered into the Fertility Heaven online database and the Fertility Heaven Match Team will suggest my profile to intended parents.

Yes, my questionnaire is complete and I will click submit below.

Terms of Use: I have read completely, understand and agree to the Fertility Heaven Terms of Use. *
Yes, I have read completely, agree and understand the Terms of Use located at http://www.fertilityheaven.com

I have educated myself on egg donation, have done my research and assessed the risks involved, and I want to be an egg donor. *

Yes

No

Before you sign up to become an egg donor, it is important that you understand what is involved in the egg donation process and thoroughly think it over. Do not complete the rest of the application if you do not check every box below showing your understanding. *

I must return all urgent text communications with Fertility Heaven within 24 hours or I may be removed from the egg donation program.
I understand most donations require multiple doctors appointments and if I agree to travel to the recipients IVF clinic out of state, I will have to visit once for one day for the initial screening exam and then return (usually within a month) for up to 5 days for the egg retrieval process. I will stay in a hotel nearby if it is more than a 2 hour drive. All the travel, hotel and food expenses will be paid for by the recipients.
The recipients will work within my schedule so that the egg retrieval fits into the time I can take away from school, work or family.
I must take injectible (shots) and oral medicine for several weeks in order to stimulate my body to make additional eggs.
I understand that Fertility Heaven will send me emails about the status of my application and important updates to my email address I list below. I should check my Spam or Trash folders in case the emails are mislabeled.

I understand the intended parents cover all my expenses in advance to include my psychological and medical evaluations, legal contract, treatment, local or out of state travel expenses and my egg donor fee. My egg donor fee will be kept in escrow by Fertility Heaven and paid to me after egg retrieval. I understand the costs involved and my obligations as an egg donor to be responsible and committed. If I change my mind later and decide not to do it for personal reasons the intended parents will not be refunded the money they invested in me. *

Yes

No

Is there anything in your genetic history, such as a history of mental and physical illness in your family that you believe may be passed down in your genes to any offspring? *

Yes

No