Fertility Center of Las Vegas - Egg Donation
Thank you for your interest in our egg donor program! We are excited at the prospect of working with you in changing peoples lives in such an amazing way. It takes an incredibly caring, giving, and selfless person to consider donation.

This program requires a person who is readily available, compliant, and fully committed to helping these deserving couples, as the process of choosing a donor can be very emotional and difficult for some. We would like to avoid any unnecessary heartache for our patients. Therefore, we ask that you fully consider the commitment prior to applying.

In order to be considered as an egg donor all applicants must fit the following requirements:
Female, age 18-29 years of age
Non-Smoker/Drug Free
Healthy Body Mass Index (BMI)
In good health, free of chronic health and genetic problems
Reliable and responsible

If you meet all these requirements please complete this online application and we will be in touch with you shortly.
We look forward to getting to know you!
1. Legal FIRST Name:
 
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2. Legal LAST Name:
 
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3. Street Address:
 
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4. City:
 
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5. State:
 
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6. Zip Code:
 
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7. What is your primary phone number?
 
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8. Are you a US citizen or permanent resident of the USA?
 
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9. Are you eligible to work in the USA?
 
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10. How many of your grandparents are full or half Native American?
 
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11. What is your date of birth?
 
   
12. What is your height? (Precise height will be calculated/verified at your first office visit.)
 
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13. What is your current weight in pounds? (Precise weight will be calculated/verified at your first office visit.)
 
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14. Have you ever been hospitalized for psychiatric care?
 
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If yes, please explain:
15. How many nicotine products (cigarettes, e-cigarettes, nicotine gum, etc.) do you use per week? (Nicotine testing will be completed in the office.)
 
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16. Do you vape or use vaping products?
 
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17. Have you ever used marijuana?
 
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18. Have you currently (within past 3 months) used any cannabis (THC) or hemp (CBD) products (including edibles, tinctures, oils, lotions, or anything that can be applied to the body or consumed)?
 
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19. Have you ever used other recreational drugs such as: Cocaine, Barbituates, Narcotics, Opiates, Amphetamines, Hallucinogens, Tranquilizers (non-medical), PCP, Inhalants, Steroids (non-medical), Ecstacy, or other recreational drugs for NON-MEDICAL purposes?
 
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Please list the name(s) of any/all recreational drug(s) used within the time frame selected above:
20. How many alcoholic drinks do you usually consume in a week?
 
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21. Have you ever been convicted of a crime?
 
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If yes, for what reason?
22. Have you ever spent time in jail?
 
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If yes, please explain:
23. Do you have both ovaries?
 
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24. How many total egg donation cycles have you completed in the past?
 
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25. Have you been diagnosed with Chlamydia or Gonorrhea within the last year?
 
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26. Have you ever been evaluated or treated for fertility issues?
 
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If yes, when and on what basis?
27. Have you ever had any procedures concerning your ovaries, uterus, or cervix?
 
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If yes, please explain:
28. What method of birth control (pregnancy prevention) are you CURRENTLY using?
 
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29. Have you ever had a Depo-Provera shot?
 
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30. Have you ever used the Mirena IUD?
 
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31. Are you currently breastfeeding?
 
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32. How did you learn about our egg donation program?
 
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If Friend/Family, please list name of the person who referred you:
33. What is your email address for communication with you regarding your pre-screen application?
   
33. Please verify your email address
   
34. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
35. Verify your password