If you need to log out before completing the application remember to save in step 12

did you meet the requirements?

Start an Egg Donor Application

We Welcome Florida Egg Donors

And Out of State Egg Donors

- Username*
- First Name*
- Last Name*
- Cell Phone*
- Address*
- City*
- State*
- Postal Code
- Country*
- E-mail*
- Password*
- Repeat Password*
- Your Age Today*
- Birth Date*
- 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).
- Please select the egg donation fee you are willing to accept. *
- 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?
  - Yes
  - No
  - Open to contact in future
- Have you ever been convicted of a crime?
  - Yes
  - No
- Are you adopted?
  - Yes
  - No
- Have you used antidepressants within the last year?
  - Yes
  - No
- Have you smoked tobacco within the last year?
  - 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, Pelvic inflammatory disease, fertility issues, ovarian, uterine?
  - Yes
  - No
- If you answered yes to any of the above please explain?
- EDUCATION & WORK
- College Education
- 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.
  - ACT
  - SAT
  - IQ
- Did you graduate from High School?
  - Yes
  - No
- Are you currently employed?
  - Yes
  - No
- Please describe the type of work you do now and in the past. Leave out specific company names.
- DONOR CHARACTERISTICS
- Height
- Weight (Insert weight in lbs)
- Eye Color
- Hair Color (Natural hair color)
- Hair Type
- Complexion
- What is your blood type?
- Plastic surgery procedures?
- What is your race?
  - White
  - Black
  - Asian
  - Hispanic
  - Native American
- What ethnic groups do you belong to? Please check those that are significant
  - Argentinian
  - Austrian
  - African American
  - Brazilian
  - Chilean
  - Chinese
  - Costa Rican
  - Cuban
  - Colombian
  - Dominican
  - English
  - Filipino
  - French
  - German
  - Greek
  - Haitian
  - Honduras
  - Hungarian
  - Indian
  - Irish
  - Italian
  - Japanese
  - Jewish
  - Korean
  - Mexican
  - Nicaraguan
  - Norwegian
  - Panamanian
  - Peruvian
  - Polish
  - Portuguese
  - Puerto Rican
  - Russian
  - Salvadorian
  - Scandinavian
  - Spanish
  - Swedish
  - Venezuelan
  - Other
- List specific ethnic groups you belong to below, separated by commas. For example Hungarian, Austrian.
- RELATIONSHIP STATUS
- Relationship Status
  - Single
  - In Relationship
  - Living Together
  - Engaged
  - Married
  - Separated
  - Divorced
- 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?
  - Yes
  - No
- Did you have braces?
  - 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.
  - Caffeine
  - Tobacco
  - Alcohol
  - Marijuana
  - Cocaine
  - None of the above
- 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.
  - None
  - HIV/AIDS
  - Gonorrhea
  - Syphilis
  - Hepatitis B
  - Hepatitis C
  - HPV
  - Herpes
  - Chlamydia
  - Other
- 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?
  - 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
- 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?
  - Yes
  - No
- What was the age of your first menstrual period?
- Are your menstrual cycles regular?
  - Yes
  - No
  - Sometimes
- How many days does your period last?
- What kind of birth control are you using?
- Please select all that apply?
  - Pregnant
  - Miscarriage
  - Abortion
  - Given birth to children
  - None
- Do you have an incidence of twins in your family.
  - Yes
  - No
- FAMILY GENETIC HISTORY
- Mother
- Mother's Age
- Ethnicity
- Height feet
- Weight
- Eye Color
- Hair Color (natural)
- Hair Type
- Complexion
- Vision
  - Perfect vision
  - Wears glasses/contacts
- Describe any health issues? If mother passed away please list date and reason
- Father
- Father's Age
- Ethnicity (Father)
- Height feet
- Eye Color
- Hair Color
- Hair Type
- Complexion
- Weight
- Vision
  - Perfect vision
  - Wears glasses/contacts
- Describe any health issues. If father passed away please list date and reason
- Do you have siblings?
  - yes
  - no
- Siblings
- ×The maximum number of fields has been reached.
  - ×+
  - Age
  - Gender
  - Height
  - Eye Color
  - Hair Color
  - Hair Type
  - Complexion
  - Weight
  - Vision
  - List Any Health Issues
  - ×+
  - Age
  - Gender
  - Height
  - Eye Color
  - Hair Color
  - Hair Type
  - Complexion
  - Weight
  - Vision
  - 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 family
  - Acne
  - ADD or ADHD
  - Adrenal Disorder
  - Alcoholism
  - Alzheimer's Disease
  - Anemia
  - Arthritis
  - Asthma
  - Autism
  - Bi-Polar
  - Blindness
  - Blood disorder
  - Breast Cancer
  - Canavan's Disease
  - Cataracts before 50
  - Cerebral Palsy
  - Cervical Cancer
  - Cleft Lip or Palate
  - Club Foot
  - Colon Cancer
  - Color Blindness
  - Crohns Disease
  - Deafness before 60
  - Depression
  - Deviated Septum
  - Diabetes
  - Downs Syndrome
  - Drug Addiction
  - Dwarfism
  - Eczema
  - Emphysema
  - Fibrosis
  - Gall Stones
  - Cystic
  - Gaucher's Disease
  - Glaucoma
  - Goiter Gout
  - Hay Fever
  - Heart Attack
  - Heart Disease
  - Hemophilia
  - Hepatitis A
  - Hepatitis B
  - High Blood Pressure
  - Hypoglycemia
  - Immune Deficiency
  - Kidney Disease
  - Learning Disorders
  - Leukemia
  - Liver Disease
  - Lung Cancer
  - Lupus
  - Manic Depression
  - Mentally Disable
  - Migrains
  - Multiple Sclerosis
  - Muscular Dystrophy
  - Myasthenia Gravis
  - Neonatal Jaundice
  - Neuro fibromatosis
  - Obesity
  - Osteoporosis
  - Ovarian Cancer
  - Ovarian Cyst
  - Paralysis Paraplegia
  - Parkinson's Disease
  - Pneumonia
  - Prostrate Cancer
  - Rectal Disease
  - Schizophrenia
  - Senile
  - Sickle Cell
  - Anemia
  - Skin Cancer
  - Skin pigmentation
  - Still born children
  - Spina Bifida
  - Stomach Cancer
  - Tay Sach's
  - Thyroid Cancer
  - Tourrettes Syndrome
  - Tuberculosis
  - Ulcer
  - Ulcerative Colitis
  - Undescended testicle
  - Uterine Fibroids
  - Wilson's Disease
  - Other Cancer
  - Other 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 PHOTOS
  Do 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.COM
- Main 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 agree

did you meet the requirements?

Start an Egg Donor Application

We Welcome Florida Egg Donors

And Out of State Egg Donors

SCREENING QUESTIONS

EDUCATION & WORK

DONOR CHARACTERISTICS

RELATIONSHIP STATUS

GENERAL HEALTH INFORMATION

MENSTRUAL CYCLE

FAMILY GENETIC HISTORY

Mother

Father

Siblings

Grandmother (Mother's side)

(Grandfather) Mother's side

Grandmother (Father's side)

(Grandfather) Father's side

FAMILY HEALTH HISTORY

PERSONALITY

PHOTOS (please click "update" after uploading photos)

UPLOAD YOUR BEST FLATTERING PHOTOS

TERMS