Egg Donor Application | Kofinas Fertility Group

Name*

First Last

Email*

Phone

Address

City

Do you live within 50 miles of Brooklyn?

Do you have reliable transportation?

Are you able to come in for a period of 8-10 days in a row for monitoring/injection appointments?

What is your age?*

What is your height?*

What is your weight?*

What is your ethnic background?*

Highest level of education achieved?

Are you currently enrolled in school?*

Date of last menstrual period?*

Are your cycles regular?

Do you currently smoke?*

Do you currently drink?

Do you currently have any medical problems?

Do you have a history of medical conditions/problems?*

Does anyone in your family have a history of medical conditions/problems?**

Do you have a history of mental disorders?*

Does anyone in your family have a history of mental disorders?*

Are you currently on birth control?*

Have you donated eggs in the past?*

Have you ever been pregnant before?*

Have you ever been treated for infertility?*

Have you ever been treated for endometriosis?*

How did you hear about our program?*

Your first step toward becoming an egg donor at Kofinas Fertility Group.