Egg Donor Questionnaire

 

Thank you for your interest in becoming an egg donor at Advanced Fertility Services, P. C. You will be assisting an infertile couple achieve their dream of parenthood. As a donor you will receive $8,000 in compensation as well as a free, comprehensive medical evaluation. Anonymity and confidentiality guaranteed. Please fill out the form and we will contact you to schedule a follow-up interview. All applicants must be between the ages of 21 and 32 and in good health.

ALL APPLICANTS MUST RESIDE WITHIN THE NEW YORK CITY METROPOLITAN AREA!

* Required
First Name*:
Last Name*:
Address*:
City*:
State*:  
Zip Code *:
We will contact you by telephone only, please enter either your home telephone and/or cell number. (Only those within the New York City Metropolitan area will be contacted.)
Home Phone Number: 
Cell Phone:
Best contact phone number?* (please enter cell number above)
 (please enter phone number above)		 
If we are unable to reach you,
may we leave a message ?*
 
Please answer these additional questions to help us evaluate you as a potential egg donor:
Have you donated before*:
Age *:

Height *:

Enter in total inches
(ex. 5'10" = 70")
Weight *: Enter in pounds (lb)
Natural hair color *:
Highest level of education *:
Ethnic background *:
Do you smoke?*: 
Are you currently taking any medications?:*
(if yes, specify, otherwise state none)
 
Do you have any current illnesses?:*
(if yes, specify, otherwise state none)
Have you ever been pregnant?*:
Do you have both ovaries?*: 
Have you ever been hospitalized or had surgery?:*
(if yes, specify otherwise state none)
Any tatoos or piercings in the last 12 months*:
Present employment if any?* 
How did you hear about us?*
(Google, Craigslist, School, Time Out, etc.)
Message:

 

 

Advanced Fertility Services, P. C.
In Vitro Fertilization Center
1625 Third Avenue, New York, NY  10128  *  Telephone:  212.369.8700

Hugh D. Melnick, M.D., Medical Director
Turning dreams into reality for 23 years
Established in 1983