Become a Donor at New Hope Fertility Clinic

First Name **

Last Name **

Address **

Address 2 / Apt. #

City **

State **

Zip **

Country **

Phone **

Email Address **

Confirm Email **

Date of Birth **

Weight **
lbs.

Height **
ft. in.

Hair Color **

Eye Color **

Race **

Ethnic Origin **

Are you eligible to work in the US? **
 Yes No

Occupation **

What is your highest level of education? **

If you chose "Other" please explain:

Have you applied or been screened to be an egg donor before? **
 Yes No

If so, where?

Have you successfully completed an egg retrieval procedure before? **
 Yes No

If so, where?

Are you currently enrolled as an egg donor in another program? **
 Yes No

If so, where?

Where did you hear about us? **

If you chose "Referral" or "Other", please specify:

Are you a smoker? **
 Yes No

Are your periods regular? **
 Yes No

Have you ever been pregnant? **
 Yes No

If yes, when and what was the outcome?

Have you ever had an abortion? **
 Yes No

If yes, when?

Have you ever had a sexually transmitted disease? **
 Yes No

If yes, what and when?

Have you ever used any kind of recreational drugs such as marijuana, LSD, heroin, ecstasy, or cocaine? **
 Yes No

If yes, please give details and date last used?

Are you currently taking any medications? **
 Yes No

If yes, what type?

List medications (not listed above) that you've taken in the past 5 years:

Have you ever had surgery (including cosmetic surgery)? **
 Yes No

If yes, what type and when?

Do you have any illnesses? **
 Yes No

If yes, what kind?

Do you or any of your family members have a history of cancer? **
 Yes No

If yes, who and what kind?

Do you have a history of birth defects in your family? **
 Yes No

If yes, who and what kind?

Have you acquired a tattoo or other skin piercing within the last 12 months? **
 Yes No

If yes, when?

Have you lived outside the US? **
 Yes No

If yes, when and where?

Please use the space below to provide any additional information you think may be relevant: