Egg Donor/Surrogate Identifying Information Application

Thank you for considering our Egg Donation/Surrogacy program!

General Information:

The information you provide on this form will be placed in our data base system. Your name will never be released without your permission. Segments of the information will also be loaded onto our web site. If you would like to see an example of the egg donation/surrogacy sections of our web site, you may visit:

Can I Apply For Being Both an Egg Donor and a Surrogate?

You are free to apply as a prospective Egg Donor, Gestational and/or Conventional Surrogate. While covered in detail in other materials (available upon request), the following is a simple summary of the three categories:

Category General Definition
Egg Donor The Egg Donor (ED) anonymously donates her eggs to an individual or
Gestational Surrogate The Gestational Surrogate (GS) agrees to provide her uterus for the
growth and delivery of child/children for the Commissioning
Couple/Intended Parent. In Gestational Surrogacy, formed embryos are
placed into her uterus and no eggs are used from the GS herself.
Conventional Surrogate The Conventional Surrogate (CS) ovulates releasing her egg wherein
sperm is placed into the uterus (insemination) to allow for fertilization.
The CS contributes both her eggs and her uterus in this process. After the
delivery, the offspring is given to the Commissioning Couple/Intended

Applying For

Understanding the above, I am applying for one or more of the categories listed below. Check all that you want to apply to:

Past Egg Donation / Surrogacy History

If you have been an Egg Donor or Surrogate in the past, please describe

If you are currently signed up with other facilities to be an Egg Donor / Surrogate, please indicate this below


Limiting Stipulations

You are free to make specific stipulations regarding what type of patient(s) you feel comfortable assisting. Please select all that you AGREE to:

If there are any other limiting stipulations, please list them below:

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