At Giving Hope, the need for Egg Donors is greater than ever.
You may be able to help one of our couples make their dreams come true.
We would be grateful if you would please
take a minute to fill out the form below and begin your
inquiry.
Your information will be handled in
strict confidence.
Thank you!
You Can Give the Ultimate Gift...
I Want To Be An Egg Donor!
Between the Ages of 21 and 30
Height and Weight Ratio Appropriate
Excellent Health
Non-smoker
Excellent Family Health History (Free of Genetic Disorders)
All Ethnic Backgrounds Accepted.
Flexibility with Job/School to Attend Doctor's Appointments
If you are sexually active, your Partner will be tested for communicable diseases
Your Physical Attributes
Age
Weight
lbs.
Height
ft.
in.
Eye Color
Natural Hair Color
Ethnicity
Select a maximum of five (5) ethnicities. Hold the Control Key (Option Key on Mac) while clicking to add/remove additional selections. If you do not see your ethicity listed, please add it to the comments below. Note: Please be specific (not Caucasian, European, Asian, etc.)
Additional Information
Birth Control
Type
Smoker
Have you Donated Before?
Occupation
Family History
(List any significant birth defects or disorders)
Your Comments
Have Comments or Questions? Ask Here!
How Did You Hear About Us?
Name?
Required Questions FDA regulations require that we ask you the following questions. Your complete honesty and accuracy are essential and appreciated. A "Yes" answer to any of the following questions will not necessarily disqualify you.
Yes
No
1.
In the past 12 months, have you had a blood transfusion?
2.
Have you ever had a blood transfusion in England, Wales, Scotland, Northern Ireland, Channel Islands, Isle of Man, Gibraltar or Falkland Islands?
3.
In the past 12 months, have you had sex with any person who has ever received human-derived clotting factor concentrates?
4.
Have you ever received human pituitary-derived growth hormone or beef-derived insulin?
5.
In the past 12 months, have you had any tissue transplantation or ever had a transplantation of cornea (covering of the eye) or dura mater (covering of the brain)?
6.
Have you or any of your blood relatives ever had Creutzfeldt-Jakob disease or been told you are at risk for it?
7.
In the past 5 years, have you used injectable (I.V.) drugs for non-medical purposes?
8.
In the past 12 months, have you had sex with someone who has used I.V. drugs?
9.
In the past 12 months, have you had sex with a man who has had sex with another man?
10.
In the past 12 months, have you had sex with any person known or suspected to have HIV infection, clinically active Hepatitis B infection or Hepatitis C infection?
11.
Provide Number In the past 6 months, how many sexual partners have you had?
12.
In the past 5 years, have you ever had sex for money or drugs?
13.
In the past 12 months, have you been exposed to known or suspected HIV, Hepatitis B, and/or Hepatitis C through infected blood by inoculation (i.e., needle stick) or through contact with an open wound or mucous membrane such as eye or mouth?
14.
In the past 12 months, have you been held in jail, prison or correctional facility for more than 72 hours?
15.
In the past 12 months, have you had any body piercings, ear piercings, tattoos, or acupuncture in which shared instruments are known to have been used?
16.
Have you ever been diagnosed with clinical, symptomatic or viral Hepatitis?
17.
In the past 2 months, have you had a smallpox vaccination or have you had contact with the smallpox vaccination site of another person?
18.
In the past month, have you had direct contact with a person with or suspected to have SARS or West Nile Virus?
19.
In the past 7 days, have you had a fever with a headache?
20.
In the past 14 days, have you had an open sore or infection?
21.
Have you, your partner or any member of your household ever had a transplant or medical procedure that involved being exposed to lives cells, tissues or organs from an animal?
22.
I understand that I must not have any vaccination within one month of egg/sperm donation.
23.
In the past 28 days, have you had a temperature >100.4, cough, shortness of breath, difficulty breathing, hypoxia or x-rays, indicating pneumonia or acute respiratory distress syndrome?
