IVF and infertility treatment -- Shady Grove Fertility

IVF and infertility treatment at Shady Grove

Brief Eligibility Questionnaire

Once you complete and submit this online form, you'll receive a call from our donor recruitment specialist, Kelly Rugola, who will answer your questions and explain the next step in the qualification process.

Only women ages 21-33 and residing in Washington DC, Delaware, Maryland, Virginia, Pennsylvania, or West Virginia are eligible to become egg donors in Shady Grove Fertility's Donor Program.

First Name:

Last Name:

Address 1:

Address 2:

City:

State:

Zip:

Email:

May we call anytime? No Yes
Phone Number:
Best time to call:

How did you hear about our program?

Questions

1.	Age:		2.	DOB:
3.	Height:	’ ”	4.	Weight:
5.	Marital status: Single Married Divorced Separated
6.	Ethnic background:
7.	Do you smoke?		No Yes
8.	Taking any medications?		No Yes– Type:
9.	Any illnesses?		No Yes– Type:
10.	Form of contraception?
11.	Have you ever been pregnant? No Yes– How Many?
12.	Do you have both ovaries? No Yes
13.	Ever donated your eggs before? No Yes– How Many?

14.	Are you adopted? No Yes
15.	Do you have any tattoos or body piercing? * We ask that once you apply you abstain from further tattoos and/or piercings.
	No Yes – How long ago:
16.	How often do you use drugs or alcohol?
17.	Have you lived or traveled outside of the United States for more than 3 months since 1980?
	No Yes– If yes, where and how long?:
18.	Have you ever been treated by a Therapist, Social Worker, or Psychiatrist?
	No Yes– For what reason: