Please indicate your current partner status and sexual orientation. Please only choose one.
Married
Unmarried but with Partner
Single (by choice, divorced or widowed)
Race:
Please select any of the races below that describe you and your partner (when one exists) understanding that both donors and recipients may be a mixture of races. Please check all of those that apply if you and/or your partner have at least 50% of a listed race in your background.
Race : Partner
Please select any of the races below that describe you and your partner (when one exists) understanding that both donors and recipients may be a mixture of races. Please check all of those that apply if you and/or your partner have at least 50% of a listed race in your background.
Religion:
You may have a predominant religion in the home which is the religion the embryo donor-conceived child will most likely be raised in. Please indicate what is the predominant religion in your home and choose only one.
Education Level:
Please indicate the highest level of education you achieved. Choose only one.
High School
College
Advanced Degree:
Education Level: Your Partner
Please indicate the highest level of education you achieved. Choose only one..
High School
College
Advanced Degree:
Contact Information
Embryo Recipient
Full Name:
Address:
Country:
City:
State:
Postal Code:
It is OK to use this
to contact me
Email
Cell Phone:
Work Phone:
Home Phone:
Do you have video
conferencing abilities?
Provider Name (i.e Skype)
User Name
Partner
Full Name
It is OK to use this
to contact me
Email
Cell Phone:
Work Phone:
Home Phone:
Do you have video
conferencing abilities?
Provider Name (i.e Skype)
User Name
Embryo Recipient General Information:
Embryo Recipient
Birth Date
Current Age
Height
feet
inches
Weight (Pounds)
Partner
Birth Date
Current Age
Height
feet
inches
Weight
Embryo Recipient Ethnic Background
The staff at EDI can sometimes guide you towards embryos with specific characteristics based on the information you provide below.
By clicking “yes” below, you will allow us to post the country in which you live in, (if in the US, the general region in which you live), the type of embryo donation procedure you have agreed to (Anonymous, Approved and/or Open Embryo Donation) and this infertility narrative to a webpage for review by potential donors. It is our hope that patients who are uncertain about donating their embryos may feel more confident about doing so after reading your story. Other information in this application will not be posted. Understanding that we want this to be your story, we would suggest the following:
Write the story as though you are speaking to the potential embryo donor.
Be specific, but not so detailed that one of your friends or family could figure out the story was yours. Please use only your first names or an alias within the story to personalize it.
Providing your areas of employment without being too specific can help paint a picture of who you are and the home in which you will raise a child. We suggest you use general terms such as “healthcare, finance, manufacturing, etc.” or other terms to further protect your privacy.
If your eduction, hobbies, unusual traits or gifts are important to you and you believe the potential donor would like to know these, please also comment on these.
Feel free to cover such areas as your motivations, partnership/marriage when appropriate, your religion if it is important to you, your hopes and dreams of conceiving, delivering and raising a child.
Explain what you have gone through thus far to have a child. If you do not have a substantial infertility history, emphasize the reasons for wanting to receive donated embryos.
Consider thanking embryo donors for making embryo donation possible.
Remember to write from the heart hoping to encourage potential embryo donors to donate their embryos.
Try to keep your story within 750 words or less. Certainly use more if you need to understanding that long stories are less likely to be read to completion. Extraordinary short stories, however, may appear incomplete.
If you agree, your story here may be featured on our various social media sites, newsletter, website and other public relation materials. EDI reserves the right to edit the stories with respect to grammar and spelling but will not significantly change the content. Not all stories submitted will necessarily be used.
If I/we do not feel comfortable with posting our story, we may keep this section blank (i.e., Only complete the narrative if you are willing to post).
You are not to feel compelled to agree for EDI to use your story. If you choose to not allow EDI to post your story, your ranking to receiving embryos as well as your medical care here at EDI will not be changed in any way.
We have read and understand the above and hereby allow EDI to list the country in which I/we currently live (the region of the country if within the US), the type of embryo donation procedure I/we have agreed to and to use my/our story to encourage patients to donate their embryos:
Embryo Recipient Signature
Partner Signature
Gynecologic History/Infertility Evaluation
Gynecologic Surgery:
Has an HSG (Hysterosalpingogram) been performed and are your Fallopian tubes open?
If your Fallopian tubes are not open or you have had them operated on, please provide details:
Has your uterine cavity been evaluated within the past two years by a sonohystergram or diagnostic hysteroscopy?
If your uterine cavity has undergone surgery, please provide details:
Obstetrical History/Children in the Home:
Embryo Recipient
Number of pregnancies:
Number of term deliveries (37 weeks gestational age or more):
Number of preterm deliveries (20 – 36 weeks & 6 days gestational age):
Number of spontaneous losses (Less than 20 weeks gestational age)
If you have had two or more spontaneous losses, have you undergone an evaluation for recurrent pregnancy loss? Did they find a reason for the losses? (Please provide details)
Number of elective terminations:
Total Number of living children:
Total Number of living children with current partner:
Number of living children with other partners:
Number of adopted children:
Is there anything else you would like to add that we have not yet asked or that you feel is important?
Partner
Number of living children with other partners:
Number of adopted children:
Completion Of Application
Typed Name(s) Below Will Act as Signature(s)
Embryo Recipient
Signed Name
Signed Date
I acknowledge that the information supplied above is true and accurate. *Note this is required to being the application processing*
Partner
Signed Name
Signed Date
I acknowledge that the information supplied above is true and accurate. *Note this is required to being the application processing*
