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Congratulations on your successful IVF and thank you for donating the opportunity of a lifetime!  
The following information will help us get started and find the right family for your embies
or you can call it takes about 3 minutes 513.518.7006!

Applicant One (Female)
In this section use your information

Street Address City State/Province Zip/Postal Code
Cell Phone Home Phone Work Fax 
Social Security Number (Optional)

Marital Status:

The Embryos Were Created By:

Biological Egg Donor (In this section use genetic information)

Please Describe Biological/Genetic Characteristics Information of The Person Who Created the Egg:

Date of Birth Age of Time of Donation
Height Weight
Hair Color Eye Color

Ethnic Background select all that apply:

Female Ethnic Background:

Ethnic Background Female

Hobbies and Interests



Applicant One's Health:

Other (please explain)


Please provide the following contact information for:

Applicant 2 Male: Use male contact information and the genetic profile information

Male  Name
  Address same as above?
Check here and skip to cell phone.
Street Address
City State/Province Zip/Postal Code
Cell Phone Work Phone Home Phone FAX
Social Security Number (Optional)

Biological or sperm donor:

Biological Sperm Donor

Date of Birth Age At Time of Donation
Height Weight
Hair Color Eye Color

Ethnic Background:

Female Ethnic Background:

Ethnic Background




Health Male

Applicant Two's Health:

Other (please explain)


HOW quickly do you want to go in the process?


 where Did You Hear about e.a.?       

Understanding of embryo Donation
briefly explain

 about the embryos

Number of Embryos to Donate

Number of Cells

Year They Were Stored:

Quality or Grade (if known)

Clinic Contact Name (if available):
Clinic Contact Email- (If available):
Name of Doctor who did the IVF:
What clinic did you use (What is the name of the clinic/facility we should contact (where embryos and records are stored):

Did you have children from these embryos?
Yes No

 DONATION preferences
About the RECIPIENT you would like

Choose From The Following Options:

Choosing of Recipient:



Age Preference of Adopters:

Number of Children: NOTE (some have adult children outside of the home or adopted)

Adoptors religion and level of importance:

Choose one of the following options:


Can The Adoptors Be From Another Country?

Level Of Openness Preference With Adoptive Family of Embryos:

Visit www.embryosalive.com for pros and cons of the levels of eligibility.

Please send pictures! Adopters like to see what the baby/s may look like!


Signature 1


Signature 2

 Note: Regarding FDA or Repeat Clinic Bloodwork--
If your embryos were stored after May 25, 2005 the recipients clinic may request repeat STD blood work
and in some cases before May 25, 2005. Although you as a Donor do not pay any fees, the adopters may
be required to have you obtain additional blood work and that additional blood work can cost adoptors
between $300.00 to $800.00 per person if not covered by your insurance-
adoptors really appreciate it if you can use your insurance and they are happy to pay your insurance co-pay as applicable.

Embryos Alive  ∞ 7741 Pfeiffer Road  ∞  Cincinnati, Ohio 45242
 ∞ Phone 513-518-7006 ∞ Fax: 727-489-2427
E-Mail: bb@cinci.rr.com or ∞ Embryosalive@yahoo.com  ∞ Web: www.embryosalive.com

The faith and political views expressed by the director are not necessarily those of the donors or adopters.