EmailMe Form - Heart To Heart Donations Egg Donor Application

Name *

First Last

Birthdate *

MM / DD / YYYY

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Cell Phone *

### - ### - ####

Email *

Preferred Contact Method

Are you willing to travel?

Race *

Ethnicity *

Father's Ethnicity *

Mother's Ethnicity *

Weight *

Height *

Feet
Inches

Natural Hair Color *

Natural Hair Type

Natural Eye Color *

Freckles

Yes

No

Skin Tone

Religion (if any)

Blood Type

Educational History

Educational Level

ACT Score

SAT Score

College GPA

Major/ Degree

Educational Background

Family History

Father

Father Age
Father Height
Father Hair Color
Father Eye Color

Mother

Mother Age
Mother Height
Mother Hair Color
Mother Eye Color

Paternal Grandfather

Paternal Grandfather Age
Height
Hair Color
Eye Color

Paternal Grandmother

Paternal Grandmother Age
Height
Hair Color
Eye Color

Maternal Grandfather

Maternal Grandfather Age
Height
Hair Color
Eye Color

Maternal Grandmother

Maternal Grandmother Age
Height
Hair Color
Eye Color

Sibling #1

Sibling #1 Age
Height
Hair Color
Eye Color

Sibling #2

Sibling #2 Age
Height
Hair Color
Eye Color

Child #1

Child #1 Age
Hair Color
Eye Color
Male or Female

Child#2

Child #2 Age
Hair Color
Eye Color
Male of Female

Personality

Describe Your Personality

Hobbies and Talents

What Kind of Music Do You Like?

Describe Yourself As A Child

What Is Your Favorite Animal and why?

If You Could Go Anywhere in The World Where Would You Go?

What Do You Consider Your Greatest Accomplishment?

Why Do You Want To Be An Egg Donor?

Do You or Have You Played Any Sports? If so, what sports and when?

Do You Speak any other languages besides English? (Please list)

What is your Favorite Food?

Health History

Do You Have Any Past or Current Medical Problems? Please Explain

General Health Condition

Family Health History---

List the family member (including yourself) with it applies to the following conditions.

Downs Syndrome

Cancer

Lund Disorders

Miscarriages

Gaucher's Disease

Kidney Disorders

Asthma

Multiple Sclerosis

Arthritis

Muscular Dystrophy

Allergies

Diabetes

Huntington's Disease

Depression / Suicide

Thyroid Conditions

Tay Sachs

Cystic Fibrosis

Sickle Cell Anemia

Blindness/ Deafness

Stillbirths

ADD (Attention Deficit Disorder)

Drug/ Alcohol Addiction

Schizophrenia

Eating Disorders

Dwafrism

Cleft lip or Palate

Spinal Bifida

Epilepsy/ Seizures

Heart Disorders

Heart Disease

Reproductive History

Number of Children

Number of Pregnancies

Number of Miscarriages

Number of Males

Number of Females

Number of Abortions

Are Your Periods Normal?

Have You Ever Undergone Infertility Treatments?

Has anyone in your family had multiple births? If so who?

Are You A Previous Donor?

Month and Date of Previous Donation

If Previous Donor Did A Pregnancy Occur?

What Method of Birth Control if Any?

Other Information

Occupation

Previous Occupation

Life Goals

Marital Status

Do You Smoke?

Yes

No

Do You Drink Alcohol?

Yes

No

If so how many drinks per week?

Something Interesting About You?

If Married, how does your husband feel about your donation? (Spouse is required to sign legal documents)

What Would you like to say to the Intended Parents?

Who is the most Important Person In Your Life and Why?

Would You Be Willing To Meet The Intended Parents?

Do You Want to Know The Results of your Donation?

FDA Questions

Ovum and embryo donations are among the most precious gifts. In order to safeguard those who donate and those who receive the gifts, careful screening and testing is required. Your complete honesty and accuracy are essential. The information collected and all the information you provide is considered confidential. The following questions are mandatory per the FDA.

Egg donation requires donors to administer medications via injections. Are you willing to administer injections or have them administered to you at a clinic?

Yes

No

Have You injected drugs for a non medical reason in the past 5 years?

Yes

No

In the past 4 weeks have you had any shots or vaccinations?

Yes

No

In the past 12 months have you had tattooing, ear, or body piercing in which shared instruments were used?

Yes

No

Have you ever been diagnosed with West Nile Virus?

Yes

No

Have any of your blood relatives ever had Creutzfeldt-Jakob disease?

Yes

No

In the past 12 months have you had a positive syphilis test?

Yes

No

In the past 12 months have you had or been treated for syphilis or gonorrhea?

Yes

No

Have You injected drugs for a non medical reason in the past 5 years?

Yes

No

Did you spend a total of 6 months or associated with a military base in any of the following countries: Belgium, The Netherlands, Germany, Spain, Portugal, Turkey, Italy or Greece.

Yes

No

Since 1980 have you ever lived in or traveled to Europe? (Include only the following countries: England, Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, or the Falkland Islands)

Yes

No

Since 1980 have you spent time that adds up to 5 years in Europe (include any time spent in the UK between 1980-1996)

Yes

No

Were you born or have you traveled to any African Country since 1977?

Yes

No

I agree that I all written representations and information provided and/or to be provided to HTHD, are true and correct

Agree To Terms

Yes

I agree to allow HTHD, to use my photos and likeness and non-identifying information from my profile to show prospective couples or individuals and for use on the internet for matching purposes only. If I choose not to display my photos on HTHD secure database, I may request as such in writing.

Agree To Terms

Yes

Print Your Name

How Did You Hear About Us?

Other comments (if any)

Upload Photos Here (Applications cannot be considered without at least 3 THREE photos. Donors are matched faster when multiple photos, current and childhood photos are best.) *

THREE PHOTOS REQUIRED TO BE CONSIDERED

Photo #2 *

THREE PHOTOS REQUIRED TO BE CONSIDERED

Photo # 3 *

THREE PHOTOS REQUIRED TO BE CONSIDERED

Educational History

Family History

Personality

Health History

Family Health History--- List the family member (including yourself) with it applies to the following conditions.

Reproductive History

Other Information

FDA Questions

I agree that I all written representations and information provided and/or to be provided to HTHD, are true and correct

I agree to allow HTHD, to use my photos and likeness and non-identifying information from my profile to show prospective couples or individuals and for use on the internet for matching purposes only. If I choose not to display my photos on HTHD secure database, I may request as such in writing.

Family Health History---

List the family member (including yourself) with it applies to the following conditions.