You may fill in the online form below, and easily return it to us by clicking on the "Submit Form" button at the end of this questionnaire.

Or if you prefer, you may print out the Recipient Preference Questionnaire, by clicking here: Print Out Recipient Preference Questionnaire and then click on "File", "Print" from the menu on your computer.

You may complete it at your leisure and mail it back to EDCD at:

EDCD
1720 Avenue K
Plano, Texas 75074
If you are unable to obtain a questionnaire by either of these methods, call us at:
972-424-9369
and we will send you one immediately.

Online Recipient Preference Questionnaire

This questionnaire is confidential. It is used only by EDCD to help us better understand your preferences and help you select your perfect donor. To help with a physical match, please send a photograph of yourself. Once we receive your completed questionnaire, you will be sent egg donor profiles at no charge, which correspond to your preferences indicated. If you desire additional profiles, simply call EDCD to request them or E-Mail us at: info@eggdonorcenter.com

This procedure must be done within the United States.
Are you willing and able to travel to the United States?
If yes, please proceed to the remaining questions.
If not, unfortunately we regret to inform you that we cannot help you at this time.
Good luck in your endeavor.
* RED STAR DENOTES REQUIRED FIELDS

 *Male Partner's Last Name      
 *Male Partner's First Name    MP-MI  
 *Female Partner's Last Name      
 *Female Partner's First Name    FP-MI  
 *Street Address  
 *City    *State    *Zip Code  

 Country  
 *Home Telephone  

 *Home E-mail

  
*Cell Phone      
 Home Fax Number     Business or 2nd E-mail  
 Male Partner-Work Telephone  

 *Female Partner-Wk. Phone

  
*Date of Birth - Female   *Date of Birth - Male  
 *Age Female    *Age Male  
 Is it permissible to call either partner at work?  

 

*Doctor's First Name    *Doctor's Last Name?  

 

*What is your doctor’s phone number?

 Who Referred you to us?  

 

MUST CHECK ONE:

*Will you be using donor sperm or your husband/domestic partner’s sperm?

*Will you be using a surrogate (gestational carrier) or carrying the child yourself?

* Please fill out the required fields, if not applicable, put N/A.

 

 

Please take a moment and answer the following as honestly and completely as possible.

1. Please describe your fertility problem.

2. *Who is to be our "contact" person throughout the cycle?

* Please fill out the required fields, if not applicable, put N/A.


3. Based on the criteria below, describe YOUR perfect donor.

 

 

A. PHYSICAL CHARACTERISTICS:

 Looks Like Female Recipient  
 Looks Like Male Recipient  

 

 

Natural Hair Color
 Blonde  
 Brown  
 Brunette  
 Red  

Hair Texture
 Straight  
 Wavy  
 Curly  
 Thick  

Complexion
 Fair  
 Medium  
 Dark/olive  
 Yellow  
 Black  

 

 

Eye Color
 Blue  
 Green  
 Hazel
 Brown  

Height Range
 up to 5'2"  
 5'3" to 5'5"  
 5'6' & up  

Weight Range
 Up to 110 lbs.  
 111-130 lbs.  
 131 & up  

Race
 Caucasian  
 Native American  
 Hispanic  
 African American  
 Asian  
 Other  




B. MEDICAL HISTORY:

 

 

Blood Type
 O  
 A  
 B  
 AB  
 Rh+  
 Rh-  

 

 

Proven Fertility of Donor
 Successful previous donation  
 Has her biological children  


 

 

C. INTELLIGENCE:

Educational Background
 High school grad  
 Some college  
 College grad  
 Post grad degree  

Minimal acceptable GPA
 up to 2.5  
 2.6-3.0  
 3.1-3.6  
 > 3.7  


Minimal acceptable SAT score
 Up to 900  
 901-1000  
 1001-1100  
 > 1100  

 

 

Minimal acceptable ACT score
 up to 19  
 20-22  
 23-25  
 > 25  

 

 

 

 

D. OTHER:

Religion of Birth
 Protestant  
 Catholic  
 Jewish  
 Islamic  
 Other  

 

 

Marital Status
 Single  
 Married  
 Divorced  
 Living Together  

 

 

Speed of Availability
 available now  
 can wait  

 

 

 

 

 

 

4. Please rate the following characteristics of an ovum donor, in the order of their importance to you. Use a scale of 1-9 with the number 1 being the most important and the number 9 being the least important.
This question may seem similar to question #4, but it is different. If you have two or more "No, I Don't Want" DONOR CRITERIA above, we must know the ORDER of their importance to you.

 Characteristic  Female Partner  Male Partner
Physical Characteristics (hair color, Eye color, etc.)    
Blood Type    
Medical History    
Proven Fertility    
Inteligence/Education Backround    
Religion of Birth    
Marital Status    
Speed of Availability    
Other Concerns    

 

 

 

 

5. Please state in your own words, the 3 most important factors to you in this endeavor, in the order of their importance (ie. speed of availability, cost, donor characteristics).

   FEMALE PARTNER    MALE PARTNER
A. A.
B.  B.
C. C.

 

 

6. Please state in your own words, the 3 most important services we can provide for you, as an agency.

   FEMALE PARTNER    MALE PARTNER
A. A.
B.  B.
C. C.

 

 


7. When do you anticipate undergoing a cycle of treatment?

Do you have any particular preferred month?


8. Please describe YOURSELF in the following spaces.

 Description

Female Partner

Male Partner
Hair Color    
Hair Texture (straight/curly/wavy)    
Complexion    
Eye Color    
Height    
Weight    
Blood Type    
National Ancestry/Race    
Religion    
Occupation    
Number of Years Married    
Education: High School Graduate?    

2. College Graduate?

3. Degrees earned and dates

    
Personal History:
Have either of you:
1. Had psychotherapy?		    
2.Filed for divorce,
dissolution, legal
separation or annulment
of this marriage?		    
3. Recently attended marriage counseling?    

 

 

 

 

9. How did you hear about us?

Friend? Who?
Doctor Referal? Who?
Found Myself on the internet.
Other?

 

 


 

If you do not receive a confirmation of receipt letter from EDCD within 72 hours of submitting this form, please call us immediately at (972) 424-9369. Thank You.


Thank you for taking the time to fill this out and help us help you. EDCD will utilize this information to provide you with donors as close to your specifications as possible. This confidential information is used only by EDCD.