Thank you so much for your interest in becoming an anonymous egg donor at Wisconsin Fertility Institute! Please take a few minutes to complete this short screening questionnaire. Once this first step is complete, we will be in touch.

Please feel free to contact us at 608-824-0075 if you have any questions while completing this questionnaire. We appreciate your time and interest!
1. First name
 
250 characters remaining "" 
2. Last name
 
250 characters remaining "" 
3. Date of Birth
 
   
4. Street address (include apartment if appropriate)
 
250 characters remaining "" 
5. City
 
250 characters remaining "" 
6. State
 
"" 
7. Zip Code
 
250 characters remaining "" 
8. Primary phone number (include area code)
 
250 characters remaining "" 
9. Is it okay to leave a message at this phone number?
 
"" 
10. What is your marital status?
 
"" 
11. What country were you born in?
 
"" 
If other, please provide country of birth.
12. Are you eligible to work in the United States?
 
"" 
13. Have you applied or been screened to be an egg donor before?
 
"" 
If yes, provide the name and location of the donor program(s).
14. Are you currently enrolled as an egg donor in another program?
 
"" 
15. Have you ever donated your eggs before? If so, how many times?
 
"" 
16. Closest description of your race. Note: Combinations of multi-racial descriptions are only in 1 menu. For example, "Black and Latin/Hispanic" is not listed in "Latin/Hispanic and Black" since they are the same.
 
If any racial descriptions include "Other", please explain.
17. Height
 
"" 
18. Weight
 
"" 
19. What is your highest level of education?
 
"" 
20. What is your current occupation?
 
250 characters remaining "" 
21. Is your work schedule flexible?
 
"" 
22. Do you currently smoke cigarettes, e-cigarettes, or use tobacco?
 
"" 
23. Have you ever used marijuana? If so, when was the last time?
 
"" 
24. Do you drink alcohol? If so, how many drinks do you usually consume in a week?
 
"" 
25. Have you ever used recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)?
 
"" 
26. If a background check were run on you, would it show any problems with the law (i.e. DUI, custody issues, lawsuits, arrests, convictions)?
 
"" 
If yes, please explain.
27. How many current sexual partners do you have?
 
"" 
28. How many sexual partners have you been with during the past 6 months?
 
"" 
29. How many sexual partners have you been with in your lifetime?
 
"" 
30. Have you ever been treated for gynecological problems such as endometriosis, ovarian cysts, fibroids, or uterine abnormalities?
 
"" 
If yes, please explain.
31. What kind of contraception do you use?
 
"" 
Explain "Other":
32. Do you have both ovaries?
 
"" 
33. Have you ever been told by a medical doctor that you were infertile?
 
"" 
If yes, please explain.
34. How many pregnancies have you had?
 
"" 
35. How many miscarriages have you had?
 
"" 
36. How many abortions have you had?
 
"" 
37. How many ectopic pregnancies have you had?
 
"" 
38. How many stillbirths have you had?
 
"" 
39. How many children have you given birth to?
 
"" 
40. Are you adopted?
 
"" 
41. 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.
 
"" 
42. By selecting "Agree", you are stating that you understand the importance of remaining anonymous to the recipient. You agree you will not share information about your egg donation experience on Facebook, Twitter, or other social media outlets. We will make reasonable efforts to protect your identity. Certain questions and answers are not shared with recipients online to protect your privacy.
 
"" 
43. How did you hear about the WFI egg donor program?
 




If you were referred by a family member or friend, they may be eligible for a referral bonus. Please provide their name.
44. Why do you want to be an egg donor?
 
250 characters remaining "" 
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.