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Michael Vermesh, MD.
Marc Kalan M.D., Nurit Winkler M.D. Specialists in
Reproductive Endocrinology/Infertility
Donor Egg Program Eligibility Questionnaire

Donor Egg Program Eligibility Questionnaire

If you are interested in becoming an egg donor, please complete this questionnaire and press submit. Our donor egg coordinator will contact you directly. The information will remain confidential, and will not be released to anyone outside our office. Please fill out as many of the fields as you can. Required fields are marked with *.

Please do not apply if you do not meet all minimum requirements.

Minimum requirements:

  • 18 - 30 years of age
  • No major medical problems
  • No more than 5 prior egg donation cycles

Contact Information:

E-mail Address:
  * required *
Name:
Address:
City:
State:
Zip code:
May we contact you?  Yes     No   
May we leave a message?   Yes     No   
Phone number:
Additional phone number:

Questions:

Age:
Date of birth:
Eye color:
Natural hair color:
Height:   feet and inches
Weight:   lbs.
Ethnic background:
Religion:
Highest level
education completed:
   
Have you ever been pregnant? Yes     No   
Do you have any children? Yes     No   
If so, how many children?
Marital status:
Do you smoke? Yes     No   
How much do you drink?
 drinks a week.

 ;
Do you, or have you
had any medical problems? 		Yes     No   
If yes, please specify.

 
Do you currently
take any medications? 		Yes     No
If yes, please specify.

 
Are you sexually active? Yes     No
If yes, what is your current
method of birth control?

 
Is your menstrual period regular? Yes     No

  


For cycle information on egg donation or surrogacy,
please contact: Giselle Martinez (818) 881-9800

Copyright © 2002-2010 - The Center for Fertility and Gynecology
Los Angeles, California. All rights reserved.

MEDICAL DISCLAIMER: The information provided in The Center for Fertility and Gynecology web site should be relied upon for medical education purposes only. It is not intended to replace the independent judgment of a health care provider. The appropriateness of a course of treatment for a patient may vary from the medical information provided herein due to individual conditions and/or complications.

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