FormOR1 - Good Egg Alliance

Donated Egg Recipient Application Form

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Name

First

Last

Birth Date (MM)

Birth Date (YYYY)

19?? ~20??

Telephone Number

Place of Birth

Are you a United States citizen or permanent resident?

If not, what is your nationality?

Ethniciity

Height (cm / feet, inches)

Weight (Kg/Pounds)

What is your current Gender?

Female Male Other

ABO Blood Types

A B AB O 不知

Rh Types

Positive Negative Unknown

Street Address

City

State

AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AS (American Samoa) DC (District of Columbia) GU (Guam) MP (Northern Mariana Islands) PR (Puerto Rico) VI (U.S. Virgin Islands)

Zip Code

Country: United State

Other Country

Eye Color

Brown Blue Black Green Hazel Gray Amber Other

Hair Color

Black Brown White Blonde Red Gray Auburn Othe

What is your relationship status?

Who do you live with? Spouse Friend Single Other

Are you willing to accommodate the schedule of a fresh egg donor?

Are you open to receiving frozen eggs?

Will you require the egg donor to undergo genetic screening for hereditary diseases?

Do you have any other specific traits or conditions you require from the egg donor?

Do you drink?

Yes No Occasionally

Do you smoke?

Yes No Occasionally

What is your highest level of education?

What is your current occupation?

Had you ever had Surgery？

If yes, what surgery you had before？

Do you have adenomyosis, myoma, or endometriosis now?

Had you have operation of cervical ionization or history of cervical incompetency ?

Had you history of getting cancer？

Do you need surrogacy？

Do you have DM, hypertension, autoimmune disease or other Internal medicine diseases?

If yes, what Internal medicine diseases you have?

Have you ever used or injected any recreational drugs or illegal drugs? (Cocaine, marijuana, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinations, tranquilizers, PCP, steroids, or others.)

If yes, which drugs, and when were they last used?

Are you currently taking any medications?

If yes, please provide the name and indication.

Have you ever been seen by a psychologist, psychiatrist, social worker, counselor, or any other medical health professional for any reason?

If yes, for how long and what reason?