EDCD - 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 downloading and printing this PDF: Recipient Preference Questionnaire.

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.