APPLICATION FOR EMBRYO DONATION EMBRYOS ALIVE
Applicant  A
Applicant B (Spouse-if applicable)
 Name: Name:
Address: Phone:
City
State, Zip:		 E-Mail:
Date of Birth: Date of Birth:
 Age: Age:
Social Security Number: Social Security
Date of Marriage: Number
of/Age/Sex Children in Home:
 
Adoption Preferences
 
Please explain briefly your interest and understanding of Embryo Donation and Adoption
 

 
Level of openness preference with adoptive family of embryos
Open: Yes No
Agency Liaison: Yes No
Closed/Anonymous: Yes No

Please explain briefly your understanding of
Open/Agency/ Liaison/ or Closed preference.

We cannot guarantee your anonymity although thorough measures are taken to protect your identity using pseudo names or
letters and numbers whenever requested
Visit www.embryosalive.com for pros and cons of the levels of eligibility.
How quickly do you want to go in the process?
As Quick as possible Just getting Started
Within a Year would be great Other Please explain
Additional Information

 

                                                                                          
                                                                                       Additional Blood work
 
        If your embryos were stored after May 2005 you may be required to obtain additional blood work and in some cases before May 2005. Although you as a Donor  do not pay any fees, the adopters may be required to have you obtain additional blood work and that additional
           blood work can  cost adoptors between $300.00 to $800.00 per person if not covered by your insurance.

   We would be willing to have any blood work submitted to our insurance (the adopters reimburse the co-pay)
    We would be willing to use Lab Corp or Quest Diagnostics or FDA approved lab if needed (if additional blood work is needed)
   We will consider the options

   Comments:
 
You may sign print and scan then fax, mail or e-mail this document to begin the embryo donation process.
 Signature : Date:
 Signature : Date: