Initial Intake Form

1Donor Inquiry
2Prequalification Checklist

First Name

Last Name

Street Address

City

Country

State

Zip Code

Phone

May we leave a message at this number?

Preferred Method of Contact

Phone

Best Time to Reach You

Morning

Afternoon

Evening

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

What is your height?

What is your current weight (lbs)?

lbs

How did you hear about our agency?

Genetic Testing

I want to be an egg donor.

I do not use recreational drugs.

I am in excellent health.

I am a non-smoker.

I understand that I cannot be an egg donor at this time if I have had tattoos or body piercings within the past six months.

I understand that I cannot be an egg donor at this time if I have used any long term form of birth control such as Norplant, Depo-Provera or hormonal IUD. in the past six months.

I have a flexible schedule and can attend several medical appointments for my participation in an egg donor cycle with notice.

I am willing to self inject medications with proper instruction for a period of 1-4 weeks for my participation in an egg donor cycle.

I am aware of the medical psychological risks associated with egg donation.

I understand that Happy Beginnings, LLC, prospective Intended Parents and other professionals will rely upon the information contained in my Application and I agree to answer each question completely and truthfully.

I understand that Happy Beginnings, LLC does not and will not provide information or advice on legal, medical, genetic, or psychological advice on the risks involved in the egg donation process.

I agree to release Happy Beginnings, LLC 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.

By submitting this questionnaire, I agree that I represent that all written representations and information provided and/or to be provided , are true, correct and complete.

I agree to the terms of service