Beverly Hills Egg Donation
468 N. Camden Dr. #200
Beverly Hills, CA 90210		 Phone: (310) 601 3132
Fax: (310) 694 9063
donorinfo@bhed.com

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Beverly Hills Egg Donation?		  
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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 "Egg donor information" section, BEFORE answering.

I understand that, if accepted as an egg donor, I will be required to self-administer injections for approximately 2-3 weeks. 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:  
In the past 12 months, have you been in jail, lock up, or prison for more than 72 hours? Yes   No  
I have attended or am attending college. Yes   No  
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, does the total amount of time you have spent in Europe add up to 5 years or more? Yes   No  
Since 1980, have you received a transfusion of blood, platelets, cryoprecipitate, or granulocytes in the United Kingdom? Yes   No  
Have you ever visited or lived in Africa? Yes   No     If Yes, please explain:  
In the past 12 months, have you been sexually active with a person known or suspected to have HIV infection, including a positive or reactive test to HIV infection, Hepatitis B infection or clinically active (symptomatic) Hepatitis C infection? Yes   No  
In the past 12 months, have you lived with (resided in the same building) another person who has Hepatitis B or clinically active (symptomatic) Hepatitis C infection? Yes   No  
In the past 12 months, have you had an accidental needle stick, sharp instrument injury, contact with human blood, serum or plasma in the eye, mucus membranes (lips, interior or nose) or sores? Yes   No  
Have you ever injected Bovine (beef) insulin? Yes   No  
Are you currently listed with any other egg donation clinics or agencies? Yes   No  
If yes, please be advised that Beverly Hills Egg Donation has an exclusivity policy, based on input from the Doctors and Recipients we work with. We require that our Donors are represented by BHED exclusively for six months. If you are currently represented by another agency (ies), you will be asked to contact them and have your profile put on hold for six months.

As part of the registration section, I understand and agree to the following:
  • All of the information contained in this application is 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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