Thanks again for everything. I can’t thank all of you enough for how easy and stress free this experience has been for me; it’s all because of the Golden Egg team!! You guys are amazing and I tell everyone how great you all have been. :) -donor

Donor Screening Form

To become an egg donor, we need to learn some information about your personal and medical history. Your responses to these questions will help us to make sure that your health and medical history are compatible with the donation process and in particular for egg donors that it will not involve any increased risks for you. This effort will also help us to match you to an appropriate recipient.

Any information you provide during the donation process, will remain completely confidential. The accuracy of the information you will be giving will provide information to potential families you may help to create, please fill out all questions with your answers.

By returning this form to Golden Egg Donation Inc, you hereby certify that the information you provided on this form is true and accurate. Thank you for your submission. After we review your form, we will contact you if you qualify to participate in our egg donor program.

Your Email Address (required):
First Name (required):
Last Name (required):
Best phone number to reach you:
Is it alright to leave a message?
Mailing Address:
Date of Birth:
Height:
Weight:
Hair Color (natural):
Eye Color:
Educational level attained thus far:
Do you smoke?
Have you used/currently use recreational drugs? If so what drugs and when (marijuana is a drug also)?
Are you sexually active?
If yes, what form of birth control do you use?
Sexually transmitted diseases: Have you or any of your sexual partners been in contact with anyone or have you been personally tested or been treated for any sexually transmitted diseases (HIV, NSU, syphilis, gonorrhea, etc.)?
Are your menstrual periods regular?
Have you ever had any medical treatment for menstrual problems?
Do you have any medical conditions?
Are you currently on any medications?
Please list any medications you have taken over the last five years:
Have you ever had any surgeries or serious illness in the past? If so what surgeries and when?
Any complications or concerns with anesthesia?
Have you ever been seen by psychiatrist, psychologist, social worker, counselor, or any other mental health professional for any reason?
Have you ever taken mental health related medications? Have you ever used medications such as anti anxiety or antidepressants to treat an emotional or psychological problem? If so what medication and when?
Have you ever been refused or denied as a blood donor? If so, why?
Have you been outside the United States for more than a 3 month period? If so please list which countries, what year and for how long?
Have you had a tattoo or piercing within the last 6 months?
Please upload a photo (optional).
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