Pre-Qualification Form

Thank you for your interest in becoming an Egg Donor in our program. To help us determine your eligibility, please complete this pre-qualification form. Please do not hesitate to contact our office directly if you have any questions regarding our program or egg donation in general. Also keep in mind that all prospective egg donors must meet the following basic criteria:

• Must be a non-smoker
• Must be between the ages of 21 and 31 and in good general health
• Must not have any sexually transmitted diseases or infections
• Must live within two hours of our Roseville, California clinic
• Must be employed
• Must not use the birth control medication Depo-Provera®
• Must not be adopted
• Must not have any family members with inheritable genetic conditions
• Must not have had an immediate family member commit suicide
• Must not have lived or stayed in the United Kingdom for three months or longer, or elsewhere in Europe for five years or longer since 1980

If you meet these criteria and feel comfortable having researched the egg donation process, please proceed to answer the following seven questions:

First Name:
Last Name:
Street Address:
City:
State:		California Alabama Alaska Arizona Arkansas Canada Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *must be in California
Zip
Email Address:
Home Phone:
Work Phone:
Cell Phone:
Fax:
Date of Birth:		Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992
Yes		I am at least 21 years of age.
Yes		I am interested in donating my eggs.
Yes		I am aware of the medical and psychological risks associated with egg donation.
Yes		I understand that NCFMC will display my profile (without my last name) and any photographs submitted by me on their website and in any other medium they determine appropriate.
Yes		I understand that NCFMC., potential recipient couples and other professionals will rely upon the information contained in my application and I agree to answer each question completely and truthfully.
Yes		I agree to release NCFMC and hold it harmless from any and all responsibility or liability with respect to any and all risks associated with the legal, medical, genetic, and/or psychological aspects of the egg donation process.
Referred by:		Website Physician Friend Other