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EMBRYOS ALIVE APPLICATION FOR EMBRYO DONATION


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

Name
Street Address City State/Province Zip/Postal Code
Country
Cell Phone Home Phone Work Fax 
Social Security Number (Optional)
E-mail (REQUIRED)

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

Education

Career/Occupation

Applicant One's Health:

Other (please explain)

Comments:

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
Country
Cell Phone Work Phone Home Phone FAX
Social Security Number (Optional)
E-mail (REQUIRED)

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

Hobbies/Interests

Education

Career/Occupation


Health Male

Applicant Two's Health:

Other (please explain)

Comments:


HOW quickly do you want to go in the process?

Other/Comments


 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:

married-or-single-or-surrogate:

Comments

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:


Comments


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

Date

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.