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Thank you for supplying information which may
be sensitive. All information is strictly confidential.
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How did you hear about us?
(Please name the specific Search Engine if you
found us on the internet.)
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Best Contact Phone #
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Date of Birth
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OK to leave a message?
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Blood
type
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Second Phone #
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Height
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OK to leave a message?
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Weight
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Best
time
to reach you?
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Eyes
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Degree
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Natural
Hair Color
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Major
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Skin
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Occupation
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Ethnic
background (German, French, Chinese, Etc)?
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Health
insurance
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Race
(Caucasian, African American, Asian, Etc.)
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Were
you
adopted?
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Marital
Status
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How
much do you smoke?
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Are
you
sexually active?
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Drink?
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If
single, in a
steady relationship?
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Use
Drugs?
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If
yes, number of sex
partners in last year
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Number
of sex
partners in lifetime
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Number
of pregnancies
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Number
of children
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Any
medical
problems?
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If
yes,
please describe |
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Do you or any members of your family suffer from any serious illness? *
Yes
No
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If so, what and who?
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Do you or any members of your family suffer from depression, or any other chronic mental illness? *
Yes
No |
If so, what and who? *
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Ever
had
surgery? *
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If
yes,
please describe |
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Any
tattoos
or body piercing? *
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If
yes, where on
body and date
received |
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Would
you be willing to donate for a single woman, a
single man, or a gay couple? (a negative
answer will not disqualify you from being
selected as a donor.) *
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Have
you ever donated for another egg donation
agency? What was the outcome? *
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Are
you currently registered with any other egg donation
agencies? *
Yes
No |
What
type of contraceptives do you presently use? (
If pills, please specify which kind you
are taking.)
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When was your last Pap Smear?
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What were the results?
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Have you ever had an abnormal Pap Smear? If so, what was the outcome?
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Have you ever had a sexually transmitted disease? If so, what was it and what was the outcome?
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Have
you ever considered surrogacy and would you like
to receive more information?
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Have you ever
used any kind of mind-altering drugs such as
marijuana, LSD, heroin, or cocaine?
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If yes, please
state details and last date used:
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Have you ever
been incarcerated? *
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Have you ever
used an injected drug or had a sexual partner who
did? *
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Have you ever
engaged in prostitution? *
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Have you been
sexually active with an HIV-positive person? *
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Have you been sexually active during the past six months? *
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Are you currently sexually active? Do you have more than one partner? *
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Are you currently in a monogamous relationship? *
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Have you ever had a gay or bisexual partner? *
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Have you, or a partner of yours, ever had a sexually transmitted disease (gonorrhea, syphilis,
hepatitis, chlamydia, herpes, condyloma, or
trichomoniasis)? If so, please describe the
diagnosis, year, and treatment: *
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Have you ever been refused as a blood donor? *
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If so, why?
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I agree that I represent that all written representations and information provided and/or
to be provided to Alternative Conceptions, and
any professional, physician, physician's
assistant, nurse, attorney, or designee of
Alternative Conceptions, are true, correct and
complete. * |
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Attention: Only submit this form once.
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Thank you for your time and
for inquiring about our program.
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