EGG DONOR CONFIDENTIAL APPLICATION

I understand that I am applying to be matched as an Egg Donor with Diversity Fertility Services. I understand that I must be a healthy female with two healthy ovaries, have no family history of cancer, have  no drug or alcohol addictions, and I must  be between the ages 19 -28 years to apply. I confirm that I meet these minimum requirements.

I  understand that information provided in this application is used only for the purpose of matching me as an egg donor.  Both my contact and identifying information are kept confidential.

I give Diversity Fertility Services permission to email, call or message me information pertaining to the egg donation process including available matches, compensation and updating my application.

arrow&v

Demographics

arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
UPLOAD HEAD SHOT PHOTO
Max File Size 15MB
UPLOAD FULL BODY PHOTO
Max File Size 15MB
UPLOAD PHOTO
Max File Size 15MB
UPLOAD BABY PHOTO
Max File Size 15MB
UPLOAD CHILDHOOD PHOTO
Max File Size 15MB
UPLOAD FAMILY PHOTO
Max File Size 15MB

Family Medical History

I understand that I am applying to be matched as an Egg Donor with the Diversity Fertility Services Egg Donor Program.  As part of the admissions process, I understand that I must fully complete the  Medical and Family History Form below. My contact information is kept confidential and used by DFS Agency and the designated IVF CLINIC for the purpose of matching me as an egg donor and completing the egg donation process. Please read our NOTICE OF PRIVACY  

Please Tell Us About Your Family's Medical History

Please carefully read the questions in each section below and tell us if you or one of your family members have been diagnosed with a specific medical condition. If no one in your family has had the medical condition listed, simply type "NA" or "Not Applicable" in the box.  If you, or one or more of your family members {your Mother, Father, Brother, Sister, Aunt, Uncle, Maternal Grandmother (your mother's mother), Maternal Grandfather (your mother's father), Paternal Grandmother (your father's mother), Paternal Grandfather (your father's father). has/had the medical condition listed, please tell us which family members have had that medical condition, what age you or your family member(s) was diagnosed, and if they got better, is still sick or died from that medical condition.

  For example, the first question in "SECTION I" asks "about Sight Issues and Age of Onset?"  If you wear glasses and your maternal grandmother is going blind then you would type in that box "I have worn glasses or contact lenses since 12 years old and my current prescription is_ _. My Maternal Grandmother has been going blind since age 88 yrs"

Section I: Neurological & Mental History

Section II: Reproductive History

Section III: Any History of Cancer in Your Family?

Section III: Any History of Cancer in Your Family?

Please Tell Us More About Your Family Demographics

New York/New Jersey

51 John F Kennedy Parkway, Short Hills, New Jersey 07078

Info@DiversityFertility.com  *  toll-free (888) 569-7790       

DFS LOGO.433.jpg