Thank you for your interest in becoming an egg donor at Atlanta Center for Reproductive Medicine.

An egg donor is a woman between the ages of 21 and 29. She can be a friend, family member, or an anonymous donor. She can be single or married and may already have children of her own.

If you are participating in an anonymous cycle, all identifying information about you is kept confidential from your recipient. You will not be given any information about the recipient or the eggs that you have donated or the outcome of your cycle.

We are excited about your interest in donating eggs to infertile couples who desperately need them! Know that these couples will be forever grateful to you for this gift! It is only by gifts such as yours that many couples can achieve their dream of having children, and we are sincerely appreciative.

Please fill out our questionnaire and we will contact you once it is completed.
1. How did you hear about us? (Select all that apply)
 















If Other, Please Explain
2. What is your FIRST name?
 
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3. Date of Birth (only your calculated age is shared with Recipients)
 
   
4. What is your height?
 
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5. What is your weight?
 
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6. What race would you most likely be affiliated?
 
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If Multi-race or Other, please provide your closest description
7. What is your highest level of completed education?
 
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Please list thedegree you are pursuing
8. Are you a US citizen or permanent resident?
 
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9. Are you eligible to work in the United States?
 
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10. Is your work schedule flexible?
 
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11. Are you adopted?
 
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12. Do you have both ovaries?
 
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13. What kind of contraception do you use?
 













If "Other", please explain.
14. Are there known genetic problems, birth defects, or mental illnesses in your immediate family? (Grandparents, Parents, Siblings or Children)
 
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If yes, please explain.
15. How many cigarettes do you smoke per day?
 
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16. When is the last time you had marijuana?
 
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17. When is the last time you have used recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)?
 
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18. FDA - In the past 12 months, have you had sex with a man who has had sex with another man in the past 5 years?
 
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Please Explain
19. FDA - In the past 5 years, have you injected drugs for a non-medical reason, including intravenous, intramuscular, or subcutaneous injection?
 
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Please Explain
20. FDA - In the past 5 years, have you received human-derived clotting factor concentrates for hemophilia or other related clotting disorder?
 
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Please Explain
21. FDA - In the past 5 years, have you had sex for drugs or money?
 
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Please Explain
22. FDA - In the past 12 months, have you had sex with anyone who would have answer "yes" to the above 4 questions?
 
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Please Explain
23. FDA - In the past 12 months, have you had sex with a person known or suspected to have HIV infection including a positive or reactive test for HIV virus, hepatitis B infection, or clinically active hepatitis C infection?
 
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Please Explain
24. FDA - In the past 12 months, have you been exposed to known or suspected HIV, hepatitis B, and/or hepatitis C infected blood through percutaneous inoculation, contact with an open wound, non-intact skin, or mucous membrane?
 
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Please Explain
25. FDA - In the past 12 months, have you been in juvenile detention, lock up, jail or prison for more than 72 consecutive hours?
 
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Please Explain
26. FDA - In the past 12 months, have you lived with (resided in the same dwelling) another person who has hepatits B or clinically active hepatitis C infection?
 
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Please Explain
27. FDA - In the past 12 months, have you had tattooing, ear piercing or body piercing in which sterile procedures were not used, e.g, contaminated instruments and/or ink were used, or shared instruments that had not been sterilized between uses were used?
 
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Please Explain
28. FDA - After the age of 11, have you ever had a diagnosis of clinical or symptomatic viral hepatitis?
 
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Please Explain
29. FDA - Within the past 8 weeks, have you had a smallpox vaccination or had close contact with the vaccination site of anyone else? (Examples of close contact include touching the site, the bandages covering the site or handling bedding or clothing that has been in contact with an unbandaged vaccination site.)?
 
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If yes, did you have any complications? If so, please explain
30. FDA - Have you been diagnosed with West Nile Virus (including diagnosis based on symptoms and/or laboratory results, or confirmed WNV viremia)?
 
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Please Explain
31. FDA - In the past 12 months, have you been treated for or had Syphilis, Chlamydia or Gonorrhea?
 
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Please Explain
32. FDA - Have you been diagnosed with variant Creutzfeldt-Jakob Disease?
 
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Please Explain
33. FDA - Have you ever been diagnosed with dementia or any degenerative or demyelinating disease of the central nervous system?
 
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Please Explain
34. FDA - Have you ever received a dura mater (brain covering) graft?
 
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Please Explain
35. FDA - Have you ever received growth hormone made from human pituitary glands?
 
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Please Explain
36. FDA - Have any of your blood relatives ever had Creutzfeldt-Jakob disease?
 
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Please Explain
37. FDA - From the beginning of 1980 through the end of 1996 did you spend time that adds up to 3 months or more in the U.K.? (includes England, Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar and the Falkland Islands).?
 
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Please Explain
38. FDA - From 1980 through 1990, were you a member of the US military, a civilian military employee or a dependent of a member of the US military, residing in US military bases in Northern Europe (Germany, Belgium and the Netherlands) for 6 months or more, or elsewhere in Europe (Greece, Turkey, Spain, Portugal, Italy) for 6 months or more from 1980 through 1996?
 
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Please Explain
39. FDA - Have you spent 5 or more years cumulative in Europe since 1980?
 
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Please Explain
40. FDA - Since 1980, have you received any transfusion of blood or blood components in the U.K. or France?
 
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Please Explain
41. FDA - Have you yourself received or had intimate contact (i.e. exchanged body fluids, including sharing toothbrushes and razors) with someone who has received organs or cells from non-human sources?
 
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Please Explain
42. By selecting "Agree", you are stating that you understand the the results of this pre-screen will be sent to you from no-reply@donorapplication.com. I understand this email must be accepted by my spam filters.
 
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43. By selecting "Agree", you are stating that you have answered all questions to the best of your ability, without purposeful omission or deception. You understand that egg donation is considered "tissue donation" according to the FDA. This is a process that requires maturity, as it is a serious issue related to all parties involved.
 
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44. By selecting "Agree", you are stating that you understand the importance of remaining anonymous to the recipient. We will make reasonable efforts to protect your identity. Certain questions and answers are not shared with recipients online.
 
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45. What is your email address for communication with you regarding your pre-screen application?
   
46. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
47. Verify your password.
   

Please add no-reply@donorapplication.com to your email contact list to prevent our response from being flagged as spam.