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Egg Donor Application

Thanks For Your Interest In Egg Donation

Thank you for your interest in our Egg Donor Program. We are grateful that you want to support those who are trying to conceive.

Your first step is to complete this intake questionnaire. It will help us learn more about you and your background. Some of the questions are very personal in nature, however your responses help us determine to what extent you may qualify to become a donor in our program. All the information you provide is confidential.

If you do have any questions or concerns about this questionnaire, please contact us at 877-260-0352 to speak with one of our egg donor specialists.

Thanks again, and let's get started!

About You

First Name(Required)
Last Name
Home Address(Required)
Date Of Birth(Required)
Are you eligible to work in the United States? You must have a social security number to be eligible.(Required)
Have you completed your high school diploma or a GED program?

Egg Donation & Birth Control History

Have you ever donated eggs before?
Are you adopted or are you a donor conceived child? You must know your biological family medical history including both parents, both sets of grandparents, and both sets of uncles and aunts.
Are you willing to take self-administered injection? There are several medications that are only administered by self-injection, and there may be up to three injections daily for about a two-week timeframe.
Are you willing to take birth control pills short term? Although this is not typically long term, we would require you to take oral birth control pills during the egg donor process.
Do you have a regular monthly menstrual cycle?

Getting Ready For The Egg Donation Process

Do you have flexibility at your work/school, so you can attend frequent appointments?
Do you have your own transportation?
Do you have a friend/family that can go to the office with you on the day of your retrieval?
Do you live within 90 minutes driving distance to one of these Brown Fertility clinics?
Jacksonville
Orlando
Winter Garden

Sexual History

Have you had sex with a man who had sex with another man within the last 5 years?
Have you injected drugs for a non-medical reason in the last 5 years, including intravenous, intramuscular and subcutaneous injection?
In the past 12 months, have you had sex with anyone who would answer yes to any of these previous questions?
In the past 12 months, have you had sex with a person known or suspected to have HIV infection, active hepatitis B infection or hepatitis C infection?
In the past 5 years, have you been given money or drugs in exchange for having sex?
In the past 12 months have you had or been treated for syphilis, chlamydia or gonorrhea?

Medical History (1 Of 2)

In the past 12 months, have you been exposed to known or suspected HIV, hepatitis B and/or hepatitis C infected blood through contact with an open wound, non-intact skin or mucous membrane?
In the past 12 months have you had an accidental needle stick, sharp instrument injury, contact with human blood, serum or plasma in the eye, mucus membranes (lips, interior of nose) or sores?
In the past 12 months, have you lived with (resided in the same dwelling) another person who has Hepatitis B or clinically active (symptomatic) Hepatitis C infection?
Have you or any of your blood relatives been diagnosed with Creutzfeld-Jakob disease (CJD)?
Have you been diagnosed with dementia or any degenerative or demyelinating disease of the central nervous system or other neurological disease of unknown etiology?
Have you ever received growth hormone made from human pituitary glands?

Medical History (2 Of 2)

Have you ever received a non-synthetic dura mater (brain covering) graft?
Are you suffering from hemophilia or do you have a coagulation disorder?
Do you have any birth defects?
Do you suffer from hereditary diseases?
Are you willing to have genetic and infectious disease testing done?

Travel History

Have you traveled outside the continental United States within the past 6 months?
Have you ever been to or had sexual contact with anyone who was born in or lived in certain countries in Africa (Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria) after 1977?
Have you received a blood transfusion or any medical treatment that involved blood in Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria?

Lifestyle History

Do you use nicotine (cigars, cigarettes, pouches, e-cigarettes, vape pens, etc.)?
Do you use marijuana every day or almost every day?
Do you take any medication?

Mental Health History

Have you ever suffered from depression or anxiety?
Have you ever been diagnosed with schizophrenia or bipolar disorder?
Are you willing to undergo a psychological evaluation?

And Finally

Have you been convicted of a crime?
In the past 12 months, have you been in jail for more than 72 consecutive hours?
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Jacksonville,   Jacksonville South,
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Albany, GA, Brunswick, GA,
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877-260-0352

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Schedule Call
  • Why Us
    • Meet Your Providers
    • Your Care Team
    • Results & Recognition
    • Physicians Praise
    • In the Media
    • Destination Patients
  • Fertility Health
    • Understanding Infertility
    • Age Factor Infertility
    • Male Factor Infertility
    • Unexplained Infertility
    • Miscarriage
    • Endometriosis
    • Polycystic Ovary Syndrome (PCOS)
    • Fertility Resources
  • Treatments
    • In-Vitro Fertilization
    • Family Balancing
    • Frozen Embryo Transfer (FET) Following IVF
    • Gestational Surrogacy
    • Intrauterine Insemination (IUI)
    • Pain-Free Hysterosalpingogram (HSG)
    • Infertility Related Surgeries
    • Timed Intercourse
    • Fertility Preservation
    • Endometrial Receptivity Assay
    • Medical Injection Services
    • Mind & Body
    • PRP Therapy
  • Egg Donation
    • Egg Donation Program
    • How to Become an Egg Donor
    • How to Become a Gestational Surrogate
    • Egg Donor Database
    • Donor Sperm
    • Embryo Donation
  • Financing Care
    • Insurance Coverage
    • Military Discount Program
    • Patient Savings Programs
    • Summer Teacher’s Program
  • Announcements
  • Events
  • Contact
    • Our Locations
    • Billing Inquiries
    • Medical Records Release