Egg Donor Application

Donor Prescreening Questionnaire

 

Helping another woman become a parent is the greatest gift you can give them. Our anonymous egg donors at Conceptions believe in families and the inner strength of every woman. Donating your eggs and supporting another woman to become a mother is a highly personal decision but one based in caring and compassion.

Egg Donor Requirements

 

We are actively seeing inspired and empowered women ages 19-33 years old to donate their eggs for patients in need.

Anonymous Egg Donors are compensated up to $7,500 for their time and effort and can donate up to six times. Qualifications to become an egg donor include:

  • Healthy women 19 to 33 years old
  • No significant personal or family history of medical/health conditions
  • No significant personal or family history of mental health conditions
  • No recent travel to Zika virus regions or current Coronavirus disease.
  • BMI between 19-29 (BMI Calculator)
  • Non-Smoker
  • No Drug Use for 12 months (No marijuana for 3 months)
  • Regular periods
  • No body piercings or tattoos for 12 months (unless using sterile technique)
  • Ok to leave a detailed message at daytime phone number?*
  • Height:
  • Weight:
  • Are you a smoker?*
  • How did you hear about our program?*
  • Have you donated before*? 
  • Do you have health insurance?
  • If yes, who is your insurance carrier:
  • Have you completed high school?*
  • What was the age of your first period?*
  • Do you have a period every month?
  • How many day between the first day or your period to the start of your next period?*
  • Do you currently use contraceptives?*
  • If yes, what type:
  • Previous contraceptive method:*
  • Do you have a history of High Blood Pressure, Heart Attack, Stroke, Migraine with Aura or Liver Disease?
  • If yes, details of diagnosis
  • Have you ever been pregnant?
  • Have you ever been diagnosed with infertility?*
  • Total number of sexual partners:*
  • Total number of sexual partners in the last 3 years?*
  • Have you ever traveled outside of the U.S.?*
  • If Yes, here have you traveled to, when and for how long?
  • Have you ever lived on/been stationed at a military base?*
  • If yes, what military base and where was it located?*
  • Please list any allergies:*
  • Please list current prescriptions:*
  • Any current personal medical illnesses?*
  • If yes, please provide details of your medical illness.
  • Have you ever been diagnosed with a blood clot, DVT, PE or a blood clotting disorder?*
  • If yes, please provide details of your medical illness.
  • Are there any medical illnesses in your family?*
  • Details of family medical illnesses:
  • Do you currently take any medications to treat a mental health illness?*
  • Name, dose and frequency of medication(s):
  • Have you or any of your family members been diagnosed with a mental health illness?*
  • Details of family mental health issues:*
  • Are you available for regular appointments between 7:00 am and 10:00 am?
  • Do you have regular access to emails and internet?*
  • Do you have a fear of needles?*
  • Have you used illicit or injectable drugs?*
  • Details of illicit/injectable drugs used:
  • Have you ever been incarcerated?*
  • Have you ever engaged in prostitution?*
  • Have you had any partners that have engaged in prostitution?*
  • Have you ever been exposed to HIV?*
  • Are you currently sexually active?*
  • Are you in a in a committed relationship with one partner?*
  • Do you have a gay partner?*
  • Do you have tattoos or body piercings?*
  • If yes, what is the date of the most recent:*

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