Ohio's Premier Reproductive Health Practice

We appreciate your interest in learning about the Donor Egg Program at The Reproductive Center. If you're a healthy female between the ages of 21 and 32, your participation in this program may allow an infertile woman to become pregnant.

There are various reasons why some women are unable to achieve pregnancy with their own eggs including premature ovarian failure and poor egg quality. Donor eggs from a woman who meets the criteria may increase the chances of pregnancy for infertile women.

If you meet the general criteria to become an egg donor and continue to have interest, the detailed questionnaire below will need to be completed along with some minor lab testing. All steps and procedures will be reviewed during your interview and a stipend will be paid for your time and generosity. Most egg donations are made anonymously.

PLEASE COMPLETE ALL FIELDS in the form below.

Last name:
First name:
Birth date:
Address:
City:
State:	Zip:
Phone:
E-mail:
Race:	Blood type:
Height:	Weight:

	Any tattoos or body piercings in the last 12 months? Yes No Please list any chronic medical problems: Please list all medications you are taking: Do you smoke? Yes No Have you ever had a sexually transmitted disease? Yes No How many pregnancies have you had? How often do you get a period?

JCAHO
American Institute of Ultrasound Medicine
American Society for Reproductive Medicine