Recipient Preference Questionnaire

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

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.

If you are unwilling or unable to travel to the United States, 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    FP-MI
 *Female Partner's First Name  
 *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 - Male *Date of Birth - Female
 *Age Male  *Age Female
 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?
1. Please describe your fertility problem. (Please take a moment and answer the following as honestly and completely as possible.)
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 Hair Texture
Blonde Straight
brown Wavy
brunette Curly
Red Thick
Complexion Eye color
Fair  Blue
Medium  Green
Dark/Olive  Hazel
Yeallow  brown
Black
height Range Weight Range
 up to 5'2"  Up to 110 lbs.
 5'3" to 5'5"  111-130 lbs.
 5'6' & up  131 & up
Race
 Caucasian
 Native American
 Hispanic
 African American
 Asian
 Other
B. MEDICAL HISTORY:

 O Proven Fertility of Donor
 A  Successful previous donation
 B  Has her biological children
 AB
 Rh+
 Rh-
C. INTELLIGENCE:
Educational Background Minimal acceptable GPA
 High school grad  up to 2.5
 Some college  2.6-3.0
 College grad  3.1-3.6
 Post grad degree  > 3.7
Minimal acceptable SAT score Minimal acceptable ACT score
 Up to 900  up to 19
 901-1000  20-22
 1001-1100  23-25
 > 1100  > 25

D. OTHER:
Religion of Birth Marital Status
 Protestant  Single
 Catholic  Married
 Jewish  Divorced
 Islamic  Living Together
 Other  
   
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.
B. 
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.
B. 
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? Degrees
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?  

Please complete the question below before clicking the submit button.

 



Copyright © The Egg Donation Center of Dallas, Inc. 2017