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Donor Application

Brief Screening Questions

Certain issues may make a woman ineligible to become an egg donor. Please read the following statements below to determine if donating eggs is a good possibility for you. These questions will be asked again in the application itself, but taking a brief moment to look over these will save you time if you’re not eligible and allow us to return your application more quickly if you are eligible. Thanks for applying!

Mandatory Conditions: If these apply to you, then you are not able to donate eggs at this time.

  • Not a U.S. citizen or permanent resident
  • Not able to work in the United States

Limiting Conditions: If these apply to you, it is more than likely that you will be unable to donate eggs at this time.

  • Younger than 21 or older than 31
  • BMI over 32 (check BMI here)
  • Smoker
  • Donated eggs more than 5 times
  • Not available for frequent appointments
  • History of alcoholism or drug abuse by mother or father
  • Family history of genetic disorder(s)
  • Have had sex with a man, who has had sex with another man
  • Have injected medicinal substances for non-medicinal purposes
  • Have offered sex in exchange for money or drugs
  • Have had sex with someone who may be assumed to have HIV or hepatitis B or C infections
  • Have had sex with someone belonging to the previous four categories
  • Have venereal warts/condyloma
  • Time Sensitive Conditions: If these apply to you, please apply after the date specified has passed.

    • Tattoo or piercing within last 12 months (apply after 12 months from date of tattoo or piercing)
    • Have been diagnosed with the Zika virus within past 6 months (apply 6 months from diagnosis)
    • Have been to or lived in area with active Zika virus transmission within past 6 months (apply 6 months after leaving area)
    • Have had sex with a male diagnosed with the Zika virus (apply 6 months after last time having sex)
    • Have had sex with a male who has been to or lived in an area with active Zika virus transmission (apply 6 months after last time having sex)





    Donor Application (* denotes a required field)

    Are you a U.S. citizen or permanent resident? *
    YesNo

    Are you eligible to work in the United States? *
    YesNo

    State *

    Race/Ethnicity *
    American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhiteOther

    Are you adopted? *
    YesNo

    Highest Level of Completed Education *

    Do you drink alcoholic beverages? *
    YesNo

    Are you available for frequent appointments? *
    YesNo

    Times in which you are NOT AVAILABLE: *
    Sunday:
    7am-9am9am-11am11am-1pm1pm-3pm3pm-5pm5pm-7pm
    Monday:
    7am-9am9am-11am11am-1pm1pm-3pm3pm-5pm5pm-7pm
    Tuesday:
    7am-9am9am-11am11am-1pm1pm-3pm3pm-5pm5pm-7pm
    Wednesday:
    7am-9am9am-11am11am-1pm1pm-3pm3pm-5pm5pm-7pm
    Thursday:
    7am-9am9am-11am11am-1pm1pm-3pm3pm-5pm5pm-7pm
    Friday:
    7am-9am9am-11am11am-1pm1pm-3pm3pm-5pm5pm-7pm
    Saturday:
    7am-9am9am-11am11am-1pm1pm-3pm3pm-5pm5pm-7pm

    Have you applied or been screened as an egg donor before? *
    YesNo

    Are you currently enrolled as an egg donor in another program? *
    YesNo

    What resources influenced your decision to apply? *
    Employee of Procreate Fertility Center of VirginiaFertilityNetwork.comOther WebsiteFacebookRadio AdNewspaperFlyerFriendPrevious DonorOther

    If you can be more specific than the above resources, it would be appreciated.

    Have you received a tattoo or piercing within the past 12 months? If so, please reapply when 12 months have passed since you received your piercing and/or tattoo. *
    YesNo

    Are you planning on having children within the next two years? *
    YesNo

    Are you planning on living at your current residence or within the Hampton Roads area during the next two years? *
    YesNo

    Does your mother or father have a history of alcoholism or drug abuse *
    YesNo

    Have you had sex with a man, who has had sex with another man? *
    YesNo

    Have you injected medicinal substances for non-medicinal purposes? *
    YesNo

    Have you offered sex to others in exchange for money or drugs? *
    YesNo

    Have you had sex with a person who may be assumed to have an HIV or hepatitis B or C infection, within the last 6 months? *
    YesNo

    Have you had sex with a person who belongs to one of the last four categories mentioned above, within the last 12 months? *
    YesNo

    Have you had any tattoos, piercings, or similar within the last 12 months? *
    YesNo

    Do you have, or have you had, venereal warts/condyloma? *
    YesNo

    Please state any types of allergies you suffer from, separated by comma. *

    Have you been diagnosed with the Zika virus in the past 6 months? *
    YesNo

    Do you live or have you traveled to an area with active transmission of the Zika virus in the past 6 months? *
    YesNo

    Have you had sexual intercourse with a male who has been diagnosed with the Zika virus? *
    YesNo

    Have you had sexual intercourse with a male who has traveled or lived in an area with active Zika virus transmission? *
    YesNo