Beverly Hills Egg Donation | Egg Donor Agency | BHED | Southern California

468 N. Camden Dr. #200
Beverly Hills, CA 90210
T (310) 601 3132
F (310) 694 9063

Egg Donor Signup - Prescreen

First Name:
Middle Name:	(optional)
Last Name:
Home Phone:
Daytime Phone:
Mobile Phone:	(optional)
Email:
Alternate Email:	(optional)
Address 1:
Address 2:	(optional)
City:
State / Province:
Zip:
How did you find out about Beverly Hills Egg Donation?	Please List:
Desired Password:	4-25 characters, no spaces
Retype Password:

Your Height:
Your Weight:	Pounds
Date of Birth:	mm/dd/yyyy
Before proceeding to the application stage, please answer the following. Please read the statements carefully, and see our "Donor information" section, BEFORE answering.

I understand that, if accepted as an egg donor, I will be required to self-administer injections for 20-30 days.	Yes No If No, please explain:
I am a female between the ages of 21 and 29.	Yes No If No, please explain:
I am a resident of the United States	Yes No If No, please explain:
I am in good health.	Yes No If No, please explain:
I use recreational Drugs.	Yes No If Yes, please explain:
I understand that, as an egg donor, I will be required to undergo a medical procedure under sedation to remove my eggs from my ovaries.	Yes No If No, please explain:
I understand that I will be required to keep approximately 4-10 different doctor's appointments throughout the process.	Yes No If No, please explain:
I am aware of the medical and psychological risks associated with egg donation.	Yes No If No, please explain:
I understand that egg donation is a very serious matter, and I will not fill out the following application unless I fully intend to, if selected for the program, follow through with all the necessary steps in the egg donation and retrieval process.	Yes No If No, please explain:
Have you visited or lived in the United Kingdom for a cumulative time of three months or more from 1980-1996 (e.g. England, Scotland, Wales, Ireland, Isle of Man, Channel Islands, Gibraltar, Falkland Islands)?	Yes No
Since 1980, have you spent time, which adds up to 5 years, in Europe?	Yes No
Since 1980, have you received a transfusion of blood, platelets, cryoprecipitate, or granulocytes in the United Kingdom?	Yes No
Have you ever injected Bovine (beef) insulin?	Yes No

As part of the registration section, I understand and agree to the following:
All of the information contained in this application are true and correct to the best of my ability.	(initials)
I understand that Beverly Hills Egg Donation will display my profile (first name and ID number only), along with some or all of the photographs I have submitted, on their website and in any other medium they determine appropriate.	(initial)
I understand that Beverly Hills Egg Donation staff, its clients (Intended Parents/potential recipients) and other professionals involved in the process will rely upon the information contained in my Application, and I agree to answer each and every question completely and truthfully.	(initial)
I understand that Beverly Hills Egg Donation does not and will not provide information or advice on the legal, medical, genetic or psychological risks of egg donation, and I agree that I am solely responsible to obtain this information and advice.	(initial)
I agree to release Beverly Hills Egg Donation and hold it harmless from any and all responsibility or liability with respect to any and all risks associated with the legal, medical, psychological, genetic, and/or any other aspects of the egg donation process.	(initial)

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