Become an Egg Donor at AsiaWest

Estimated completion time:
3-5 minutes

We welcome applicants between the ages of 20-28 who have a BMI between 18 and 28, are non-smokers with no history of substance abuse, are physically and psychologically healthy, have regular menstrual cycles, and reside in the United States. College-educated applicants are highly desirable.

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1. What is your first name? *

2. What is your last name? *

3. What is your mailing address? *


Address
Suite/Apt/Bldg
City
State
Zip Code
Country

4. In which country were you born? *

5. Are you a US citizen or permanent resident? *

6. Are you eligible to work in the United States? *

7. What is your cell phone number (include area code) to use for contact and leaving messages? *

8. Do you give us permission to text you? *

9. Which ethnicity do you identify with (select all that apply)? *

10. What is your mother's ethnic country of origin? *

11. What is your father's ethnic country of origin? *

12. What is your height? *

13. What is your weight (lbs)? *

14. What is your date of birth? *

15. Are you adopted? *

16. Do you have a drivers license or state issued ID? *

Estimated completion time:
3-5 minutes

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1. Have you taken Depo Provera in the last 6 months? *

2. What is your highest level of education and degree earned? *

3. What college(s) did you attend or are you currently attending? If none, enter "N/A"

Not Applicable to Me

4. Have you had a baby in the last 6 months? *

5. Do you have Implanon/ Nexplanon implants? *

6. Do you have both ovaries? *

7. Have you ever been diagnosed with ADD/ADHD? *

8. Have you ever used medications such as anti-anxiety or anti-depressants to treat an emotional or psychological problem? *

8a. Please provide additional information on anti-anxiety or anti-depressants medications. *

	Medication name	Reason for taking	Length of time taking	Currently taking (Yes/No)
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
	Add Row

9. Are you comfortable donating to same-sex couples? *

10. Have you applied or been screened to be an egg donor before? *

11. How many times have you donated? *

12. Do you currently or have you ever smoked cigarettes and/or vaped nicotine? *

13. Have you ever used recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids) for non-medical reasons? *

14. Upload Photos
Please upload 1-2 recent photos.
Please note: You can upload more photos later on with your full questionnaire.
*

15. How did you hear about us? *

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Questionnaire

Become an Egg Donor with AsiaWest

Become an Egg Donor with AsiaWest

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