If you need to log out before completing the application remember to save in step 12 Start an Egg Donor Application Username* First Name* Last Name* Cell Phone* Address* City* State* Postal Code Country* United StatesAlbaniaAlgeriaAndorraAngolaAntiguaBarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBoliviaBosnia and HerzegowinaBotswanaBrazilBruneiBulgariaCambodiaCameroonCanadaCosta RicaCote d-IvoireCroatiaCyprusCzech RepublicDenmarkDominicaDominican RepublicEcuadorEgyptEl SalvadorEstoniaEthiopiaFijiFinlandFranceGeorgiaGermanyGhanaGibraltarGreeceGrenadaGuadeloupeGuamGuatemalaGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKorea-North KoreaKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritiusMexicoMicronesiaFederated States of MoldovaMonacoMongoliaMoroccoMozambiqueNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNorwayOmanPakistanPalauPanamaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaSaint KittsSaint LuciaSaint Vincent and the GrenadinesSamoaSaudi ArabiaSenegalSeychellesSingaporeSlovakiaSloveniaSouth AfricaSpainSri LankaSurinameSwazilandSwedenSwitzerlandRepublic TaiwanChinaTajikistanTanzaniaThailandTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab Emirates United KingdomUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaVietnamWallis and Futuna Islands WesternSaharaYemenZambiaZimbabwe E-mail* Password* Repeat Password* Your Age Today* Birth Date* Have you ever donated your eggs before?*YesNo 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). Please select the egg donation fee you are willing to accept. * -70008000900010000 Other fee (specialty donor, Ivy league, high IQ) AMH Genetic Result Where did you learn about Fertility Heaven?* SCREENING QUESTIONS Would you like to be anonymous to recipients?YesNoOpen to contact in future Have you ever been convicted of a crime?YesNo Are you adopted?YesNo Have you used antidepressants within the last year?YesNo Have you smoked tobacco within the last year?YesNo Have you ever been hospitalized for substance abuse, depression, or any other psychological problem?YesNo Does your family have any history of cancer or heart disease under the age of 55?YesNo Have you ever been diagnosed with any gynecological issues such as fibroids, ovarian cysts, endometriosis, Pelvic inflammatory disease, fertility issues, ovarian, uterine?YesNo If you answered yes to any of the above please explain? EDUCATION & WORK College Education Enrolled in collegeAssociates DegreeBachelor's degreeMaster's DegreeOther Please list the college and degree you are pursuing and have achieved or certificate program completed? What is your highest college GPA? Check the tests you have taken.ACTSATIQ Did you graduate from High School?YesNo Are you currently employed?YesNo Please describe the type of work you do now and in the past. Leave out specific company names. DONOR CHARACTERISTICS Height 5 feet5 feet 15 feet 25 feet 35 feet 45 feet 55 feet 65 feet 75 feet 85 feet 95 feet 105 feet 116 feet Weight (Insert weight in lbs) Eye Color BlueGreenHazelBrown Hair Color (Natural hair color) BlondeRedLight BrownBrownBlack Hair Type StraightWavyCurlyCoarse Complexion LightFairMediumOliveBrownBlack What is your blood type? O+O-A+A-B+B-AB+AB-Unsure Plastic surgery procedures? What is your race?WhiteBlackAsianHispanicNative American What ethnic groups do you belong to? Please check those that are significantArgentinianAustrianAfrican AmericanBrazilianChileanChineseCosta RicanCubanColombianDominicanEnglishFilipinoFrenchGermanGreekHaitianHondurasHungarianIndianIrishItalianJapaneseJewishKoreanMexicanNicaraguanNorwegianPanamanianPeruvianPolishPortuguesePuerto RicanRussianSalvadorianScandinavianSpanishSwedishVenezuelanOther List specific ethnic groups you belong to below, separated by commas. For example Hungarian, Austrian. RELATIONSHIP STATUS Relationship StatusSingleIn RelationshipLiving TogetherEngagedMarriedSeparatedDivorced Name of contact in case of emergency Relationship of contact to you? Emergency contact number GENERAL HEALTH INFORMATION What is your eye vision? Have you had surgery to correct your vision?YesNo Did you have braces?YesNo How is your hearing? What is your sexual orientation? Do you have health insurance?YesNo How many glasses of alcohol do you drink per week on average?01-34-67-10>10 Do you take any drugs or prescription drugs?YesNo Please check if you have used any of the following. Many clinics require drug testing before you will be qualified to donate.CaffeineTobaccoAlcoholMarijuanaCocaineNone of the above Have you had any of the following?TattoosBody PiercingAcupunctureBlood TransfusionsNone 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.NoneHIV/AIDSGonorrheaSyphilisHepatitis BHepatitis CHPVHerpesChlamydiaOther Please list any illnesses, hospitalizations, operations or surgeries you have had and the date Have you, or any family member, ever been under the care of a psychiatrist?YesNo Have you, or any family member, ever received treatment for drug and/or alcohol abuse?YesNo Have you had counseling or psychotherapy?YesNo Are there any medical conditions for which you are currently being seen or treated?YesNo Please describe the details if you answered yes to any of the questions above. MENSTRUAL CYCLE When was your last pap smear and what were the results? Have you ever had an abnormal pap smear?YesNo What was the age of your first menstrual period? Are your menstrual cycles regular?YesNoSometimes How many days does your period last? What kind of birth control are you using? Please select all that apply?PregnantMiscarriageAbortionGiven birth to childrenNone Do you have an incidence of twins in your family.YesNoFAMILY GENETIC HISTORYMother Mother's Age Ethnicity Height feet 5 feet5 feet 15 feet 25 feet 35 feet 45 feet 55 feet 65 feet 75 feet 85 feet 95 feet 105 feet 116 feet Weight Eye Color BlueGreenHazellight brownBrown Hair Color (natural) BlondeRedLight BrownBrownBlack Hair Type StraightWavyCurlyFineCourse Complexion LightFairMediumOliveBrownBlack VisionPerfect visionWears glasses/contacts Describe any health issues? If mother passed away please list date and reason Father Father's Age Ethnicity (Father) Height feet 5 feet5 feet 15 feet 25 feet 35 feet 45 feet 55 feet 65 feet 75 feet 85 feet 95 feet 105 feet 116 feet6 feet 16 feet 26 feet 36 feet 46 feet 5 Eye Color BlueGreenHazellight brownBrown Hair Color BlondeRedLight BrownBrownBlack Hair Type StraightWavyCurlyFineCourse Complexion LightFairMediumOliveBrownBlack Weight VisionPerfect visionWears glasses/contacts Describe any health issues. If father passed away please list date and reason Do you have siblings?yesnoSiblings×The maximum number of fields has been reached.×+ Age Gender Height Eye Color BlueGreenHazelBrown Hair Color BlondeRedLight BrownBrownBlack Hair Type StraightWavyCurlyFineCourse Complexion LightFairMediumOliveBrownBlack Weight Vision Perfect visionNeeded glasses/contacts List Any Health Issues ×+ Age Gender Height Eye Color BlueGreenHazelBrown Hair Color BlondeRedLight BrownBrownBlack Hair Type StraightWavyCurlyFineCourse Complexion LightFairMediumOliveBrownBlack Weight Vision Perfect visionNeeded glasses/contacts List Any Health Issues Please list all half siblings here and cover the same questions you did for your first siblings: Grandmother (Mother's side) 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) Mother's side 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 (Father's side) 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) Father's side 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: FAMILY HEALTH HISTORY 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 familyAcneADD or ADHDAdrenal DisorderAlcoholismAlzheimer's DiseaseAnemiaArthritisAsthmaAutismBi-PolarBlindnessBlood disorderBreast CancerCanavan's DiseaseCataracts before 50Cerebral PalsyCervical CancerCleft Lip or PalateClub FootColon CancerColor BlindnessCrohns DiseaseDeafness before 60DepressionDeviated SeptumDiabetesDowns SyndromeDrug AddictionDwarfismEczemaEmphysemaFibrosisGall StonesCysticGaucher's DiseaseGlaucomaGoiter GoutHay FeverHeart AttackHeart DiseaseHemophiliaHepatitis AHepatitis BHigh Blood PressureHypoglycemiaImmune DeficiencyKidney DiseaseLearning DisordersLeukemiaLiver DiseaseLung CancerLupusManic DepressionMentally DisableMigrainsMultiple SclerosisMuscular DystrophyMyasthenia GravisNeonatal JaundiceNeuro fibromatosisObesityOsteoporosisOvarian CancerOvarian CystParalysis ParaplegiaParkinson's DiseasePneumoniaProstrate CancerRectal DiseaseSchizophreniaSenileSickle CellAnemiaSkin CancerSkin pigmentationStill born childrenSpina BifidaStomach CancerTay Sach'sThyroid CancerTourrettes SyndromeTuberculosisUlcerUlcerative ColitisUndescended testicleUterine FibroidsWilson's DiseaseOther CancerOther Disease 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. PERSONALITY Why do you want to be an egg donor? What are your special talents and hobbies? (Artist, Athlete, Dancer, Musician, Singer) What has been your favorite vacation and why? What are your favorite foods? What has been your biggest personal or professional achievement? PHOTOS (please click "update" after uploading photos)UPLOAD YOUR BEST FLATTERING PHOTOSDo not upload photos with filters, hats, sunglasses or from far distances. Please resize large photos. Ideal photos are 300 x 300 for uploading. If you have difficulty uploading photos and video email them to INFO@FERTILITYHEAVEN.COMMain profile photo - Camera facing*Upload Camera facing includes your whole bodyUpload Fun PhotoUpload Sport or Activity PhotosUpload Your Choice PhotoUpload Photo with Big SmileUpload Photo with Parents or SiblingsUpload Photo of you as an InfantUpload Photo of you as a ToddlerUpload Photo of you from age 4 to 10Upload Upload video of less than 30 secondsUpload TERMS 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 or health history of myself or my immediate family members which includes parents, siblings, grandparents, aunts, uncles and cousins, which must be ascertained to determine if I am a good genetic candidate for egg donation. I understand that if I cancel the cycle, I will be responsible for reimbursing the intended parents the costs for my medical expenses. I have educated myself on egg donation. I have done research and read the Fertility Heaven egg donor pages to educate myself on the process. I have assessed the risks involved, and I want to be an egg donor. Do you agree to the above stated terms?*Yes I agreeDo you want a copy of this form sent to you by email?
