Donor Registration Form

Admin

Donor Type

Donor Personality

1. Date of Birth

2. Race

3. Eye Color

4. Hair Type

5. Height (cm)

6. Weight (kg)

7. BMI

8. Body Build

Education/Social

9. Level of Education

10. Favourite Subject in School

11. Current Occupation

12. Talents and Interests

13. Favourite Color

14. Favourite Food

15. Favourite Season

16. Favourite Holiday Place

17. What is the total Number of your Existing Children

17a. How many are Donor Children?

18. Marital Status

19. Religion

Medical History

20. Do you have any allergies? If yes, please specify.

21. Do you suffer from any chronic illnesses such as High Blood Pressure, diabetes, asthma, epilepsy, HIV, Autoimmune disease, endocrine disease, or any other genetic disease?

22. Have you experienced recurring physical symptoms that have not been evaluated by a physician yet?

23. Do you have any physical handicap or deformities

24. Do you suffer from any of the following disease traits? Sickle cell disease, Thalassemia, Haemophilia, Porphyria, Heart problems, Cancer, Diabetes, Asthma, Epilepsy, Autoimmune disease, Thyroid disease, other endocrine diseases, Any other genetic disease?

25. How is your vision without glasses

26. Do you wear glasses/contacts?

27. Do you have any dental problems?

28. Have you ever worn braces/retainer?

29. Have you ever had surgery or complications resulting from surgery? if yes, what surgery or complications?

30. Have you ever been hospitalized? if yes, please explain.

31. Have you ever had major radiation/x-ray exposure?

32. Have you ever had blood transfusion?

33. Do you have tattoos?

34. Do you smoke cigarettes/shisha/e-cigarettes?

35. Do you use recreational drugs? e.g. cocaine, meth, marijuana, other intravenous drugs, etc?

36. Have you ever been treated for substance/alcohol abuse or addiction?

37. Have you ever been with a partner who uses drugs, intravenous or otherwise?

38. Do you have multiple sexual partners?

39. Do you have a mental illness e.g. Schizophrenia, major depression, bipolar mood disorder? If yes, please state the condition.

40. Do you have any legal cases pending?

Family History

41. Race/nationality of genetic mother and father

42. What is the profession of your genetic mother and father

43. What is the natural hair color of your mother and father

44. What are the eye color of your mother and father

45. Do any of your family members suffer from or have traits for any of the following: Sickle cell disease, Thalassemia, Porphyria, Haemophilia, Heart Problems, Diabetes, Asthma, Epilepsy, Auto Immune Disease, Thyroid disease, Other endocrine disease, Any other genetic disease, born with physical deformities, Learning disorders, Fertility problems, Psychiatric or mental disorders?

46. Has anyone in your family been diagnosed with heritable cancers such as breast, ovarian, endometrial or colon cancer especially at a young age before 40 years?

Donation Preferences

47. Will you donate to couple or single persons?

48. Will you donate to mixed race couple?

49. Please state any additional donation preferences

Photos

Childhood Photo (before age 10)

Chilhood Photo2

All information provided is correct and pictures are all of me. I consent to participate in the Borrowdale Fertility donor program and participate as required and understand the concept of anonymous egg donation and claim no further rights over any child or children cinceived of egg donation. I agree that i will be prescribed medication to potentially synchronise my menstrual cycle with that of the recipients. I alsoagree to receive medication to stimulate my overies and have a surgical procedure to harvest the eggs. I agree to keep Borrowdale Fertility updated about my availability and the number of egg donation pregnancies achieved with Borrowdale Fertility or any other egg donation program that i have participated in.