Expanding patient knowledge...
from thought to conception... and beyond
Streamlining the Gift of Life Processes...
from thought to conception... and beyond

Donor Application Form

Tell us about yourself
1. Are you eligible to work in the United States?
2. Are you a US citizen or permanent resident?
3. What is your FIRST name?
4. What is your LAST name?
5. What is your email address?
6. What is your mailing address?
Street City State/Province Zip/Postal Code Country
7. How far away from our practice do you live?
8. What is the primary phone number (include area code) to use for contact and leaving messages?
Ext.
9. What is your date of birth?
10. What is your height?
11. What is your weight?
12. What is your eye color?
13. What is your natural hair color?
14. What race would you most likely be affiliated?
Other race or self-description of race
15. Are you adopted?
16. What is the ethnic origin of your mother? (e.g. French, Irish)
17. What is the ethnic origin of your father? (e.g. French, Irish)
18. How many years of college did you complete?
19. What is your current occupation?
20. Do you have medical insurance?
21. Have you been vaccinated in the past 12 months?
If yes, what were you vaccinated for?
22. Are you currently under a physicians care for any reason?
If yes, please explain.
23. List all medications that you have taken in the proceeding 12 months (prescription). Enter "N/A" in the first box if you have not taken medications.
Rx Medications Medication How Often Reason
1
2
3
4
5
6
7
24. List all current over-the-counter medications (including hormones, vitamins, aspirin, antacids, laxatives, herbal & sports supplements, performance-enhancing supplements including steroids, etc.). Enter "N/A" in the first box if you have not taken any OTC medications.
OTC Medications Medication How Often Reason
1
2
3
4
5
6
7
25. Do you or your family or relatives have birth defects, genetic diseases, or serious medical problems?
If yes, explanation required.
26. Do you or your family or relatives have any history of any significant emotional or psychological problems (depression, bipolar, ADD, etc)?
If yes, explanation required.
27. How long is your monthly menstrual cycle (first day of one period to first day of the next)? (In days)
28. Have you ever had trouble conceiving? If yes, when and why?
If yes, when and was the cause identified?
29. How many pregnancies have you had?
30. To how many children have you given birth?
31. How many cigarettes do you smoke per day?
32. When is the last time you had marijuana?
33. When is the last time you used other recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids, or etc.)?
If yes, which one(s)?
34. Have you ever been convicted of a felony?
If yes, explanation required.
35. Does anyone in your family have a family history of alcoholism, drug use, abuse, or addiction?
If yes, please list who and additional details (such as currently struggling, in therapy, sober for 2 years, etc)
36. Have you applied or been screened to be an egg donor before?
If yes, provide the name and location of the donor program(s).
37. How many times have you donated?
38. Are you currently enrolled as an egg donor in another program?
39. Do you have other skills/hobbies/talents/interests (i.e. writing, reading, ability to do games or crossword puzzles, handcrafts)? Describe.
40. Please add additional comments or questions:
41. Are you currently pregnant or trying to get pregnant?
42. Are you currently breastfeeding?
43. What resources did you use and/or impacted your decision to apply?
Jinxin International AIA Medical Management Service Orga.
BEIJING US LIFE Bestcare Health Management
BESTIME BluedBaby
Brightening Consultants (used to be SHANG'S IVF CONSULTING AND MARKETING INC.) Cheung Kong Life
GENDER DREAMING GENDER SELECTION AUSTRALIA
Graeme and Hayley Trust GROWING GENERATIONS
HONGTAO YU IVF Plus Consulting Company
IVF Universal LEYUN Inc. (Jiechengmeiyun Medical Consulting Company)
Lijun Ding Magic Journeys Inc.
Meng Mei Nanjing Aiyunmei Medical Technology Co., Ltd
Other Agency
PARALIAN TECHNOLOGY, INC.
Qiu NanXiong Recovery International Medical
Shanghai Heyuen Health Management Shedoor International, dba Xi Duo International (Shao Xiao)
Shenzhen Manyue Management Consulting SURRO CONEXION, LLC
Trecare Medical Management Company US-Sino Healthcare Mgmt Co. Ltd
Xuhong Wan (NEW STAR BABIES) Yinzhi Tang
FairFax
Facebook Live - Dr. Becht Facebook Live - Dr. Boostanfar
Facebook Live - Dr. Chavkin Facebook Live - Dr. Coffler
Facebook Live - Dr. Feinman Facebook Live - Dr. Frederick
Facebook Live - Dr. Kolb Facebook Live - Dr. March
Facebook Live - Dr. Nelson Facebook Live - Dr. Norian
Facebook Live - Dr. Peck Facebook Live - Dr. Potter
Facebook Live - Dr. Tourgeman Facebook Live - Dr. Wilcox
Other
Seminar - Dr. Becht
Seminar - Dr. Boostanfar Seminar - Dr. Chavkin
Seminar - Dr. Coffler Seminar - Dr. Feinman
Seminar - Dr. Frederick Seminar - Dr. Kolb
Seminar - Dr. March Seminar - Dr. Nelson
Seminar - Dr. Norian Seminar - Dr. Peck
Seminar - Dr. Potter Seminar - Dr. Tourgeman
Seminar - Dr. Wilcox Webinar - Dr. Becht
Webinar - Dr. Boostanfar Webinar - Dr. Chavkin
Webinar - Dr. Coffler Webinar - Dr. Feinman
Webinar - Dr. Frederick Webinar - Dr. Kolb
Webinar - Dr. March Webinar - Dr. Nelson
Webinar - Dr. Norian Webinar - Dr. Peck
Webinar - Dr. Potter Webinar - Dr. Tourgeman
Webinar - Dr. Wilcox
Email
Friend or Family HRC Employee
Other
Recipient
Google Search
Aetna Anthem Blue Cross Blue Shield
Cigna Healthcare Partners
Healthnet Kaiser Permanente
Other
Pacificare
Progyny Sharp Healthcare
Tricare Insurance United Health Allies
United Healthcare
Conceive Magazine Inland Empire Magazine
Ladera Ranch Lesbian News Magazine
Los Angeles Magazine New York Times
Newspaper OC Family
OC Register Orange Coast Magazine
Other
Outlook Paper
Parenting OC Pasadena Magazine
Riviera Magazine The Fight Magazine
Verizon Directory
Channel Q 103.1 Chinese Radio 1300 AM
KFI AM 640 KIIS-FM 102.7
MY FM 104.3 Other
Persian Radio 670 Radio 98.7
Radio Ad La Mejor 96.7
Returning Patient
Facebook Instagram
LinkedIn Other
Pinterest Yelp
Youtube
Fertilityproregistry.com Gender Dreaming
IntegraMed Other
Pop Luck Club Resolve
Sart.org Web MD
Other
Anxiety Depression
Marital problems Stress

Your privacy is very important to us. Information collected here will only be shared with HRC Fertility which may contact you as a follow up.