Egg Donor Application | Her Helping Habit

Do you have a valid passport?

Have you ever been convicted of a crime, felony or have pending charges against you/promise to appear? (This may affect your ability to travel).

Yes

Do you have a clean criminal record?

Yes

Why do you want to become an egg donor?

Would you be willing to be a known egg donor?

This means your identities are exchanged between you and your recipients to allow the exchange of necessary information for the both of you down the road. Sometimes these types of donations can develop into friendships organically.

How do you envision your ideal relationship with the recipients of your eggs?

Would you be interested in surrogacy as well at any time in the future?

Would you be willing to travel to donate?

Do you have any diagnosed medical conditions?

Do you have any undiagnosed medical condition(s) or health concerns under investigation?

Have you ever been told that you are infertile?

Is there a history of infertility in your family?

Are you currently taking injectable medication?

If you are sexually active, do you get regular STI tests?

Have you engaged in prostitution at any time?

Have you had close contact with someone suspected or known to be positive for Hepatitits A, B, C or HIV? (i.e. sexual intimacy, shared bathroom or kitchen)

Have you received any transfusions of blood or taken any medications with blood components?

Have you ever been refused as a blood or organ donor?

Have you ever received human organ or tissue transplant?

Have you been bitten by an animal suspected of having rabies within the past 12 months?

Have you ever been diagnosed with vCJD or any form of CJD?

Do you have any tattoos or piercings?

Have you travelled to an at risk Zika Virus Zone(s) in the past 12 months?

Have you been exposed to radiation or toxic chemicals in your work or personal life (i.e. Lead, mercury, gold)?

Are you currently taking any medications or vitamins?

Have you been prescribed any medication in the last 5 years?

Have you ever sought psychological counselling?

Have you, or are you currently taking medication for a psychological condition?

Is there anyone in your family diagnosed with a psychological condition?

Have you ever attempted suicide?

This does not necessarily exclude you from the egg donor program?

Please provide any other information that may be relevant but hasn't been covered in regard to emotions.

Have you ever used recreational drugs?

Do you drink alcohol?

Do you smoke nicotine products?

i.e. cigarettes

Do you vape any type of subtance?

Do you smoke or ingest marijuana?

Would you be willing to refrain from using all substances during the egg donation process?

This would start when you agree to donate to a specific clinic and parents until your retrieval occurs. Please expect to refrain for 3-6 months.

Do you have any plans to travel outside of the country in the next year?

Have you ever donated before?

Are you a part of any other Egg Donor Program?

Do you have any questions or concerns about the egg donation process?

We will go over these during your consult

I, the undersigned, have read the oocyte donation information above. I hereby acknowledge that all the information I have provided on this oocyte donation application have been answered fully and correctly, to the best of my knowledge and that my answers and explanations were voluntarily given.

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