Online Application to Donate Embryos
Embryos Alive

Thank you for allowing us to help you find a match for your embryos.

Donor Mom Contact Information
Name
Street Address
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
Cell
E-mail
Donor Dad contact information
Name
 Address
(if different)
Work Phone
Home Phone
Cell
E-mail
Female Biological or Egg Donor

Biological
Egg donor

Marital Status

Female Profile Please Use Biological or Egg Donor Information
Date of Birth
Age (at time of Donation)
Height
Weight
Hair Color
Eye Color
Ethnic Background

Various European           Bi-racial (please state which races)             Irish
 Caucasian                     India                                                     Not sure
 African American            Canadian                                                Other
 Hispanic                        Italian
 Asian

 

Hobbies and Interests?

Career

Health

Excellent            Poor
 Good                  Other (please explain)
 Fair

 

Comments

Applicant 2 Male

Please use male bio or sperm donor information

Biological
Sperm Donor

Marital Status Male

Male personal profile

Age (at time of donation)
Height
Weight
Hair Color
Eye Color

Ethnic Background Male

Various European                   Canadian             Bi-racial (please explain)
 Caucasian                            English                Other
 Hispanic                               India                  Not sure
 African American                   Asian

 

Hobbies and Interests Male

Career/Occupation Male

Health (Male)

Excellent            Poor
 Good                 Other (please explain)
 Fair

 

Health Please Explain

How Quickly Do You Want To Go?

As quickly as possible
 A year would be great
 Just getting started
 Currently pregnant so after birth (due date is...)

Please explain


How Did You Hear About Us?

 Please explain briefly your understanding of Embryo adoption


About The Embryos

Number of Embryos to Donate

Number of Cells

2 PN pre nuclear
 3 Days
 5 days
 Blastocysts (Blasts)
 Not sure
 Other

Year They Were Stored?

Quality or grade (if known)?


Please request the form from your clinic so they can send you a copy of your embryology results, blood lab results (and if you used an egg or sperm donor please request their summary called "letter of eligibility")

Pictures are always requested! Identifying information will be blacked out.

ABOUT THE FAMILY YOU WOULD LIKE TO CHOOSE

Adoptor Preferred

Married
 Single
 Either

Age Preference of Adoptors

Number of Children Adoptors Could Have

Adoptors Religion and level of Importance

Level of Importance?

Can the adoptors be from a foreign country?

Yes
 No
 Case By Case Basis

Please Explain Your Understanding of Open/Email/Agency Liaison/or Closed Adoption


 Although we cannot guarantee your anonymity although procedures and thorough measures are taken to protect your identity whenever requested
Visit www.embryosalive.com for pros and cons of the levels of eligibility.

Level of Openness

Open
 E-Mail
 Agency Liaison
 Closed

           
Signature                                                   Signature                        

 

 Note: Regarding FDA or clinic bloodwork--
If your embryos were stored after May 2005 you may be required to obtain additional blood work
and in some cases before May 25, 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-
adoptors really appreciate it if you can use your insurance and they just pay your co-pay.
 

Please e-mail pictures! Adoptors like to see what the baby/s will look like!



   www.EmbryosAlive.com        
Office 513-793-1593      Fax 513-793-0052      Alt. Fax 727-489-2427

                                                    Revised: 07/30/08

Copyright © 2008 Embryos Alive All rights reserved.