Code Name (select a female name followed by 3 numbers)

First Name

Last Name

Email Address

Have you ever been convicted of a crime?
YesNo

Are you adopted?
YesNo

Can provide a full genetic history?
YesNo

Do you have any sexually transmitted diseases?
YesNo

Do you think you could pass a psychological examination?
YesNo

Are you willing to take a drug test, complete a psychological evaluation, and attend 5-10 local appointments for screening and monitoring?
YesNo

Have you given egg donation a lot of thought and consideration?
YesNo

Have you researched and understand the risks involved with egg donation?
YesNo

I will return all phone calls, texts and emails from GS Moms within 24 hours.
YesNo

Birth Date

Address

What is the nearest city to you?

What is your home phone number?

What is your cell phone number?

Is your cell phone a smart phone?
YesNo

What is the lowest fee you are willing to take for your first egg donation between $3,500 and $10,000?

Please list a code name that you will be known as during the process

What kind of relationship would you like to have with the parents?

Are you willing to report any new health issues that you may have in the future to the attorney of the recipients?
YesNo

Have you donated eggs before?
YesNo

Have you used antidepressants within the last year?
YesNo

Have you smoked tobacco within the last year?
YesNo

Are you still smoking?
YesNo

If so, how many cigarettes do you typically smoke a week?

If not, when did you quit?

How many cigarettes a day were you smoking before you quit?

Have you ever been pregnant?
YesNo

What kind of birth control are you using?

Have you seen a doctor in the past year for any reason?
YesNo

Please list the dates and reasons you have visited a doctor in the last year

Have you ever been hospitalized for substance abuse, depression, or any other psychological problem?
YesNo

Please describe

Do you have a major credit card?
YesNo

Height

Weight

What is your relationship status?
SingleIn a RelationshipEngagedMarriedDivorced

Partner's name and contact information

Emergency contact information

Are you between the age of 19 and 29?
YesNo

How did you hear about GS Moms?
FriendWorkSchoolCraigs ListBarefoot StudentSearch EngineOther

If you heard about us on Craigslist or Barefoot Student, what city was that ad posted in?

If you heard about us from your college or university, what school are you attending?

How many children do you have?

Are you currently a student?
YesNo

Do you have a degree? If so, please list or let us know where you are at in your studies. Please also provide the college or university name and your current GPA.

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