www.optionsinconception.com - A negative blood type ancestry

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Dear Applicant,

Thank you for considering egg donation to help others in need. Enclosed is the application packet, which begins with standard screening questions, followed by the Egg Donor Profile. Please send the completed and signed forms, along with pictures of you (childhood + adult), and of your children (if applicable) to:

by fax:

949.585.9363

Attention: Robin

by email:

info@

or by mail:

Options in Conception

16300 Sand Canyon Ave, Suite 904

Irvine, CA 92618

If you have any questions, please feel free to call us. Thank you.

Sincerely Yours,

The Team at Options in Conception

Chinese: 626.388.7606

English: 949.585.9339

Korean: 714.833.7478

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|Initial screening questions |Y |N |don’t Know |Comments |

|Egg Donor | | | | |

|Intended Parents | | | | |

|Have you injected drugs for a non-medical reason in the last 5 years, | | | | |

|including intravenous, intramuscular, or subcutaneous injection? | | | | |

|Do you have a clotting disorder for which you have received | | | | |

|human-derived clotting factor concentration? | | | | |

|Have you had sex for drugs or money in the past 5 years? | | | | |

|In the past 12 months, have you given money or drugs to anyone to have | | | | |

|sex with you? | | | | |

|Have you had sex in the past 12 months with anyone who would answer yes| | | | |

|to the above 4 questions? | | | | |

|Female: In the past 12 months, have you had sex with a man who has had | | | | |

|sex with another man in the past 5 years? | | | | |

|Male: Have you had sex with another male in the past 5 years? | | | | |

|In the past 12 months, have you had sex with a person known or | | | | |

|suspected to have HIV, or active hepatitis B or C? | | | | |

|In the past 12 months, have you been exposed to known or suspected HIV,| | | | |

|hepatitis B, and/or hepatitis C infected blood through pericutaneous | | | | |

|inoculation, contact with an open wound, non-intact skin, or mucous | | | | |

|membrane? | | | | |

|In the past 12 months, have you been in close contact (i.e. sharing | | | | |

|kitchen and bathroom) with a person having active viral hepatitis? | | | | |

|In the past 12 months, have you had tattooing, ear or body piercing in | | | | |

|which shared instruments were used? | | | | |

|After the age of 11, have you ever had viral hepatitis (Hep A excluded:| | | | |

|IgM anti-HAV test)? | | | | |

|Have you yourself received or had intimate contact (i.e. exchanged body| | | | |

|fluids, including sharing toothbrushes and razors) with someone who has| | | | |

|received organs or cells from non-human sources? | | | | |

|Have you had a recent smallpox vaccination? | | | | |

|In the past 4 weeks have you had any shots or vaccinations? | | | | |

|Have you been diagnosed with West Nile Virus (defer at least 28 days | | | | |

|from date of diagnosis or 14 days from the date condition is resolved; | | | | |

|whichever is later)? | | | | |

|Have you had a blood transfusion or infusion within the past 48 hours | | | | |

|before your blood test for eligibility? If so, algorithms must be used| | | | |

|to determine if plasma dilution is a problem. | | | | |

|Have you ever received growth hormone made from human pituitary glands?| | | | |

|Have you ever received a dura mater (brain covering) graft? | | | | |

|Have any of your blood relatives ever had Creutzfeldt-Jakob disease? | | | | |

|In the past 12 months, have you had a positive syphilis test? | | | | |

|In the past 12 months, have you had or been treated for syphilis or | | | | |

|gonorrhea? | | | | |

|In the past 12 months, have you been in jail for more than 3 days in a | | | | |

|row? | | | | |

|From 1980 through 1996, were you a member of the US military, a | | | | |

|civilian military employee or a dependent of a member of the US | | | | |

|military? | | | | |

|Since 1980, have you ever lived in or traveled to Europe? (Includes: | | | | |

|England, Ireland, Scotland, Wales, the Isle of Man, the Channel | | | | |

|Islands, Gibraltar, or the Falkland Islands) | | | | |

|Have you been in a place affected by SARS or with an affected person | | | | |

|with in the past 14 days? | | | | |

|Have you been treated for SARS in the last 28 days? | | | | |

|Were you born in, have you lived in, or have you traveled to any | | | | |

|African country since 1977? | | | | |

|When you traveled to _______, did you receive a blood transfusion or | | | | |

|any other medical treatment with a product made from blood? | | | | |

|Have you had sexual contact with anyone who was born in or lived in any| | | | |

|African country since 1977? | | | | |

Patient (print) Signature

Date / / Time : AM PM

Witness (print) Signature

Date / / Time : AM PM

|Office Use Only. |

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|Accept ( Reject ( |

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|Physician ___________________________________ |

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|Date _______________ Time ___________________ |

EGG DONOR PROFILE

The Information on This Page Will be Kept Confidential.

Date Form Completed:

|Name: AKA: |

|Date of Birth: / / Age: |

|Address: |

|City: State: Zip: |

|Home Phone: ( ) - Cell: ( ) - |

|Work Phone: ( ) - Fax: ( ) - |

|Email: |

|U.S. Citizen: Yes No Social Security Number: |

|If you are not a U.S. citizen, please indicate your citizenship: |

|Driver’s License Number: State: |

|Other ID/Passport Number: |

|Occupation: Employer: |

|Health Insurance Carrier: |

|Policy Holder: Group #: Policy #: |

|Emergency Contact: Relationship: |

|Phone Numbers: ( ) - and ( ) - |

|Marital Status: Married Single Divorced Separated |

|Widowed Committed Relationship |

|Name of Partner: |

|Partner’s Date of Birth: / / |

|Partner’s Social Security Number: / / |

|Do you have reliable transportation? |

|Are you willing to travel out-of-state or travel by air for procedure? |

|How did you hear about us? |

EGG DONOR PROFILE

The Following Information Will be Included in Your Profile.

|BASIC INFORMATION |

|Age: Occupation: Blood type: Confirmed Date: |

|Religious background: |

|Marital status: ⁪ Married ⁪Single ⁪Divorced Separated |

|Widowed Committed Relationship |

|PHYSICAL DESCRIPTION |

|Height: Weight: Eye color: Natural hair color: |

|Hair texture: Straight Wavy Curly Thin Average Thick |

|Complexion: Fair Medium Olive Dark Freckles |

|Physical build: Petite Average Heavy Other |

|Predominant hand: Right handed Left handed Ambidextrous |

|ETHNIC ORIGIN |

|(Please be specific – French, Chinese, German, etc.) |

|Maternal: |

|Paternal: |

|EDUCATION |

|Years of high school completed: GPA: SAT Score: |

|Years of college completed: GPA: |

|Post-Graduate Education: |

|Major: Degree: |

|Educational goals: |

|Any other training or certificates?? |

|Have you had an IQ test? Yes No |

|If yes, list date and scores: |

|Do you have any learning disabilities? Yes No |

|If yes, please explain: |

|DONATION HISTORY |

|Have you been an egg donor previously? Yes No |

|If yes, please answer the following questions. |

|Date |

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|Which agency? |

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|Overall experience |

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|How many eggs were retrieved? |

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|Did a pregnancy occur? |

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|Anny complications? |

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|PERSONALITY |

|Which of the following describes you best? Check all that apply: |

|Extrovert Passive Dependent |

|Slight introvert Warm Shy |

|Slight extrovert Happy Moody |

|Introvert Sensitive Lonely |

|Aggressive Energetic Quiet |

|Assertive Independent Other : |

|Please describe your childhood: |

|Please describe your personality and character: |

|What are your favorite books? |

|What are your favorite movies? |

|What is your favorite color? |

|What are your favorite foods? |

|What are your favorite stores to shop or restaurants to eat at? |

|What was your favorite subject in school? |

|Please describe any special talents, skills, or abilities you have: |

|What languages do you speak? |

|What kind of sports, activities, and/or hobbies do you enjoy? |

|Where would you like to travel to and why? |

|Who are the most important people in your life? |

|What is your philosophy in life? |

|What is the reason you want to be an egg donor? |

|Is there anything else you would like to tell us about yourself? |

|MENSTRUAL HISTORY |

|Present form of birth control: |

|Do you have regular, predictable menstrual periods? Yes No |

|How often do you have menstrual periods? |

|Every days my period comes. It lasts days. |

|PREGNANCY HISTORY |

|Have you ever been pregnant? Yes No |

|For all previous pregnancies (including abortions and miscarriages). Please list the following information: |

|Year Type Delivery Outcome Complications |

|1. |

|2. |

|3. |

|4. |

|5. |

|Have you ever had trouble getting pregnant? Yes No |

|If yes, please explain: |

|Did your parents have difficulty conceiving? Yes No |

|Do any of your family members, including siblings, have fertility issues? Yes No Explain: |

|YOUR CHILDREN |

|1. Female Male Hair color: Eye color: Any health problems? |

|2. Female Male Hair color: Eye color: Any health problems? |

|3. Female Male Hair color: Eye color: Any health problems? |

|4. Female Male Hair color: Eye color: Any health problems? |

|5. Female Male Hair color: Eye color: Any health problems? |

|HEALTH INFORMATION |

|Blood type: RH factor: Positive Negative |

|Are you under a physician’s care for any reason? Yes No |

|If yes, please explain: |

|Current medications (include vitamins, aspirin, antacids, etc.) |

|Medication Frequency Reason |

|1. |

|2. |

|3. |

|4. |

|List all allergies and your reaction to each: |

|Allergen Reaction |

|1. |

|2. |

|3. |

|What is the condition of your teeth? Excellent Good Fair Poor |

|How is your diet? Vegetarian Non-vegetarian |

|Excellent Good Fair Poor |

|Are you adopted? Yes No |

|If yes, do you know your medical history? Yes No |

|Please list any significant illnesses you have had: |

|Were you ever hospitalized as a child or adult? Yes No |

|If yes, please explain: |

|Do you currently smoke cigarettes, marijuana, or use any type of illegal substances? Yes No |

|If yes, which type and how many per day? |

|Do you drink alcohol? Yes No |

|If yes, how many drinks per week? |

|Do you have any history of alcohol abuse? Yes No |

|If yes, please explain: |

|Have you ever used IV drugs? Yes No |

|If yes, please explain: |

|Have you ever been under the care of a psychiatrist? Yes No |

|If yes, please explain: |

|Have you ever been convicted of a crime/felony? Yes No |

|If yes, please explain: |

|Have you had any body piercings? Yes No Date: / / |

|Have you had any tattoos? Yes No Date: / / |

|Have you had a smallpox vaccination? Yes No Date: / / |

|Have you ever been treated for syphilis or gonorrhea? Yes No |

|If yes, please explain: |

|Have you or any of your partners had the following diseases? |

|Non-specific Urethritis Yes No Myself Partner When |

|Chlamydia Yes No Myself Partner When |

|Venereal Warts Yes No Myself Partner When |

|Herpes Yes No Myself Partner When |

|Other STD Yes No Myself Partner When |

|EXERCISE INFORMATION |

|How often do you exercise? Regular Occasional None |

|What type of exercise? |

|MEDICAL HISTORY |

|Do you have or have ever had the following: |

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|Yes |

|No |

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|Yes |

|No |

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|Cancer |

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|Asthma |

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|Diabetes |

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|Pneumonia |

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|Hypertension |

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|Bronchitis |

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|High cholesterol |

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|Tuberculosis |

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|Heart disease |

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|Hepatitis/Liver disorder |

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|Scarlet fever |

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|Ulcers |

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|Mitral valve prolapse |

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|Colitis/Enteritis |

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|Heart murmur |

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|Kidney disorder |

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|Psychiatric disorder |

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|Rubella |

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|Seizures |

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|Measles |

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|Stroke |

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|Mumps |

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|Bleeding disorder |

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|Chicken pox |

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|Anemia |

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|Mononucleosis |

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|Thyroid disorder |

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|Serious injury/accident |

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|Recent immunization |

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|Blood transfusion |

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|Blood clots in legs/lungs/heart |

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|Anesthetic complication |

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|If you answered yes to any of the above, please explain. |

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|Yes |

|No |

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|Yes |

|No |

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|Wear glasses |

|Prescription/Explanation |

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|Prolonged bleeding |

|Cosmetic surgery/Explanation |

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|Wear contact lenses |

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|Bleeding from gums |

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|Double vision |

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|Nose bleeds |

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|Blind spots |

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|Denture/bridge |

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|Unable to smell |

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|Breast discharge |

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|Sinus problems |

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|Breast mass |

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|Hay fever |

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|Fibrocystic changes |

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|Ringing in ears |

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|Breast implants |

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|Hearing loss |

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|Mammogram |

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|Take Aspirin/Ibuprofen frequently |

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|Do monthly breast self-exam |

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|Chest pain |

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|Excessive hair growth |

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|Irregular heartbeats |

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|Acne |

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|Fainting spells |

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|Skin disorder |

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|Leg swelling |

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|Rash |

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|Calf pain |

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|Hives |

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|Varicose veins |

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|Skin cancer |

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|Cough |

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|Abdominal pain |

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|Shortness of breath |

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|Nausea and vomiting |

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|Wheezing |

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|Vomiting blood |

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|Cough up blood |

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|Ulcer |

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|Chest x-ray |

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|Food intolerance |

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|TB skin test |

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|Gallstones |

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|Bladder infections |

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|Jaundice/Hepatitis |

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|Kidney infection |

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|Chronic constipation |

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|Painful urination |

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|Diarrhea |

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|Urgent/frequent urination |

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|Blood in bowel movement |

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|Easy bruising |

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|Bowel endoscopy |

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|Blood/abnormal color of urine |

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|Abnormal liver function tests |

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|Unable to control urination |

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|Abnormal thyroid function |

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|Abnormal urinary tract |

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|Enlarged thyroid |

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|Kidney x-ray |

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|Hemorrhoids |

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|Bladder cystoscopy |

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|Colitis/Enteritis |

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|Anemia |

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|Irritable bowel |

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|Heat or cold intolerance |

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|Sensation loss/numbness |

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|Arthritis |

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|Nerve/head injury |

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|Disc disease |

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|Bowel x-ray |

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|Back pain |

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|Muscle control/weakness |

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|Counseling |

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|Hernia |

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|Psychiatric treatment |

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|Damp skin |

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|Recent stress increase |

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|Unusual hair loss |

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|Recent weight change |

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|Extraordinary fatigue |

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|Recent anxiety increase |

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|If you answered yes to any of the above, please explain. |

|Headaches: Yes No |

|If yes, number per week Medication used |

|Mild Moderate Severe Stress related |

|Improving Worsening No change Migraine |

|With visual changes With vomiting |

|FAMILY MEDICAL HISTORY |

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|Have you or has anyone in your family had the following: |

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|Yes |

|No |

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|Yes |

|No |

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|Neural tube defects |

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|Cystic fibrosis |

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|Spina bifida/Anencephaly |

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|Canavan disease |

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|Thalassemia |

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|Muscular dystrophy |

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|Down syndrome |

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|Huntington chorea |

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|Autism |

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|Mental retardation/Fragile X |

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|Gaucher’s disease |

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|Chromosomal disorder |

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|Sickle cell disorder or trait |

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|Congenital heart defect |

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|Alzheimer’s disease |

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|Baby with birth defects |

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|Tay-Sachs disease |

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|Hemophilia |

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|Club foot |

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|Cerebral palsy |

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|Parkinson’s disease |

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|Cleft palate/lip |

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|Cancer |

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|Deafness |

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|Hypertension |

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|Multiple sclerosis |

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|Heart disease |

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|Diabetes |

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|High cholesterol |

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|Stroke |

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|Other |

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|If you answered yes to any of the above, please indicate which family member it applies to: |

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|MOTHER |

|Current age: Ethnic ancestry: |

|Heights: Eye color : Natural hair color: |

|Hair texture: Straight Wavy Curly Thin Average Thick |

|Complexion: Fair Medium Olive Dark Freckles |

|Level of education: |

|Occupation: |

|Special skills, talents, or interests: |

|Personality traits: |

|General health: |

|Age at death and cause of death (if applicable): |

|FATHER |

|Current age: Ethnic ancestry: |

|Heights: Eye color : Natural hair color: |

|Hair texture: Straight Wavy Curly Thin Average Thick |

|Complexion: Fair Medium Olive Dark Freckles |

|Level of education: |

|Occupation: |

|Special skills, talents, or interests: |

|Personality traits: |

|General health: |

|Age at death and cause of death (if applicable): |

|MATERNAL GRANDMOTHER |

|Current age: Ethnic ancestry: |

|Heights: Eye color : Natural hair color: |

|Hair texture: Straight Wavy Curly Thin Average Thick |

|Complexion: Fair Medium Olive Dark Freckles |

|Level of education: |

|Occupation: |

|Special skills, talents, or interests: |

|Personality traits: |

|General health: |

|Age at death and cause of death (if applicable): |

|MATERNAL GRANDFATHER |

|Current age: Ethnic ancestry: |

|Heights: Eye color : Natural hair color: |

|Hair texture: Straight Wavy Curly Thin Average Thick |

|Complexion: Fair Medium Olive Dark Freckles |

|Level of education: |

|Occupation: |

|Special skills, talents, or interests: |

|Personality traits: |

|General health: |

|Age at death and cause of death (if applicable): |

|PATERNAL GRANDMOTHER |

|Current age: Ethnic ancestry: |

|Heights: Eye color : Natural hair color: |

|Hair texture: Straight Wavy Curly Thin Average Thick |

|Complexion: Fair Medium Olive Dark Freckles |

|Level of education: |

|Occupation: |

|Special skills, talents, or interests: |

|Personality traits: |

|General health: |

|Age at death and cause of death (if applicable): |

|PATERNAL GRANDFATHER |

|Current age: Ethnic ancestry: |

|Heights: Eye color : Natural hair color: |

|Hair texture: Straight Wavy Curly Thin Average Thick |

|Complexion: Fair Medium Olive Dark Freckles |

|Level of education: |

|Occupation: |

|Special skills, talents, or interests: |

|Personality traits: |

|General health: |

|Age at death and cause of death (if applicable): |

|SIBLING |

|Sister Brother |

|Current age: Heights: Eye color : Natural hair color: |

|Hair texture: Straight Wavy Curly Thin Average Thick |

|Complexion: Fair Medium Olive Dark Freckles |

|Level of education: |

|Occupation: |

|Special skills, talents, or interests: |

|Personality traits: |

|General health: |

|Age at death and cause of death (if applicable): |

|SIBLING |

|Sister Brother |

|Current age: Heights: Eye color : Natural hair color: |

|Hair texture: Straight Wavy Curly Thin Average Thick |

|Complexion: Fair Medium Olive Dark Freckles |

|Level of education: |

|Occupation: |

|Special skills, talents, or interests: |

|Personality traits: |

|General health: |

|Age at death and cause of death (if applicable): |

|SIBLING |

|Sister Brother |

|Current age: Heights: Eye color : Natural hair color: |

|Hair texture: Straight Wavy Curly Thin Average Thick |

|Complexion: Fair Medium Olive Dark Freckles |

|Level of education: |

|Occupation: |

|Special skills, talents, or interests: |

|Personality traits: |

|General health: |

|Age at death and cause of death (if applicable): |

|SIBLING |

|Sister Brother |

|Current age: Heights: Eye color : Natural hair color: |

|Hair texture: Straight Wavy Curly Thin Average Thick |

|Complexion: Fair Medium Olive Dark Freckles |

|Level of education: |

|Occupation: |

|Special skills, talents, or interests: |

|Personality traits: |

|General health: |

|Age at death and cause of death (if applicable): |

|SIBLING |

|Sister Brother |

|Current age: Heights: Eye color : Natural hair color: |

|Hair texture: Straight Wavy Curly Thin Average Thick |

|Complexion: Fair Medium Olive Dark Freckles |

|Level of education: |

|Occupation: |

|Special skills, talents, or interests: |

|Personality traits: |

|General health: |

|Age at death and cause of death (if applicable): |

CONFIDENTIAL

The following information will be kept confidential.

Are you able to comply with the following requirements?

Egg donors are required to have infectious disease screening tests at the expense of the prospective parents.

Yes No

Egg donors must abstain from sexual activity while undergoing the egg donation cycle.

Yes No

Egg donors are required to attend approximately 8 to 10 appointments throughout the donation cycle.

Yes No

Egg donors are required to take self-administered injections for approximately three weeks.

Yes No

Egg donors are required to undergo a procedure under sedation to remove the eggs from their ovaries.

Yes No

Egg donors are required to have reliable transportation for appointments.

Yes No

Egg donors are required to have a driver on the day of the egg retrieval.

Yes No

No legal fees, psychological testing fees, medical testing fees or medical procedure fees will be charged to the applicant or her partner. However, any expenses incurred (mileage, babysitting, etc) while applying to the　program and throughout the egg donation process are the responsibilities of the egg donor.

I consent to being notified of any medical information discovered about me during the egg donation process.

I AUTHORIZE THE RELEASE OF ANY NON-FICTIONAL INFORMATION AND PHOTOGRAPHIC MATERIAL ENCLOSED IN THIS APPLICATION.

I CERTIFY THAT ALL THE INFORMATION PROVIDED IS COMPLETE AND TRUE TO THE BEST OF MY KNOWLEDGE.

Electronically signed

Name of the egg donor applicant (print) 　 Signature of egg donor applicant 　　　　 Date　　　　　　　　

Electronically signed

Name of witness (print) 　　　　　　 Signature of witness Date

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