The first step in the egg donation process is to complete a medical history and genetic questionnaire. Our donor egg department will review your history and questionnaire and you will be contacted if you qualify to be a potential egg donor.
  
Donor profiles are made available to couples who are seeking donor eggs.  The questionnaire allows the recipient couple to select an egg donor who best matches their own physical characteristics and background.
  
There are no out of pocket expenses incurred by donors.
Donors who complete the cycle are compensated $3,000.

 
First Name:
Last Name:
Address:
City:
State:
Zip:
eMail:
Phone number:
Center:

Please answer these additional questions
to help us evaluate you as a potential donor:
Have you donated before?
Yes
No
Age
Height:
Weight:
Marital Status:
Highest level of education:
Ethnic Background:
Do you smoke?
Yes
No
Are you currently taking medication?
Yes (specify)
No
If yes, please specify:
Do you currently have any illnesses?
Yes (specify)
No
If yes, please specify:
Have you ever been pregnant?
Yes
No
Do you have both ovaries?
Yes
No

Past Medical History

 
Diabetes
No
Yes
Thyroid
No
Yes
S.T.D. *
No
Yes
If yes, please list which below:

* (STD = sexually transmitted diseases)

 
Depression
No
Yes
Anxiety
No
Yes

OB History

 
No. of children
No. of terminations
If children or terminations, list dates

Surgery / Hospitalizations

 
Provide history (if any)

Other

 
Allergies (if any)
Drug usage (if any)
Alcohol usage (if any)
Alternative medicines used (if any)
Known genetic diseases (if any)
Tattoos - when last (if any)
Piercings - when last (if any)
How did you hear about us?
Please check all that apply
Integramed.com
TV
Newspaper
Magazine
Midwest Fertility Specialists website
Radio
Physician
Friend
NUVO
Other: 

   
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