Test Form Page - Egg Donation Cape Fertility

Egg Donor Application Form (#17) (#22)

Detailed Donor Profile
Physical Characteristics
Personality Character
Lifestyle
Family Heritage & Characteristics
Medical History
For Office Use Only

Ethnic Heritage

Egg Donor As a Child

We will insert childhood pictures up to age 11 years that you provide in this space.

Couples look at baby pictures when selecting a donor and we want you to be selected! Face pictures that clear are ideal!

We will add them to the end of your profile.

You can upload your pictures here. If you are unable to do so don't worry! We will contact you and ask you to WhatsApp or email them.

Uploaded pictures must be less than 3 Meg in size. If you are unable to upload pictures you can email or WhatsApp them to us [linda@capefertility.co.za | 066 22 55 003].

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Short Summary Profile

Race (parents-to-be often look for donors that resemble themselves, so this data is important to them)

Asian

Black

Caucasian

Coloured

Indian

Mixed Race

In which city do you live

Will you travel to Donate? - If not based in Cape Town, and with all costs paid, are you prepared to travel to Cape Town to donate? You will be required to make a 1 day trip and then a 9 nights stay trip about 6 weeks later. If you are NOT prepared to travel please stop completing this application as this is a requirement.

Yes

Year of Birth

Nationality - E.g., South African, British, Zimbabwean etc...

Are you adopted?

Yes

Do you have any biological children?

Yes

Is there a history of twins in your family?

Yes

Have you ever donated before?

Yes

Thank you for filling in the form so far!

You are in good company. Here's what one of our Donor Angels had to say about the experience:

Being an egg donor was an amazing experience for me. It’s something that I’ve always thought of doing and having this opportunity to help out another was very fulfilling. The staff were extremely helpful and I always felt safe and comfortable, even moments before the retrieval. I never felt alone in this process and I would definitely donate again to help somebody else start their family. Thank you so much.

Congratulations!!!

You have earned your Egg Donor Angel feathers.

Keep on going with the next section...

Personality & Character

Height

Weight

BMI - We will complete this

Eye Colour

Black

Brown

Blue

Green

Hazel

Blue/Grey

Blue/Green

Natural Hair Colour

Black

Brown

Light Brown

Dark Brown

Blonde

Strawberry Blonde

Dark Blonde

Red

Natural Hair Texture

Thick

Thin

Wavy

Small Tight Curls

Ethnic

Complexion if you are Caucasian

Fair

Medium

Olive

Complexion if you are Black

Light

Medium

Dark

Complexion if you are Indian

Light

Medium

Dark

Complexion if you are Mixed Race

Light

Medium

Dark

Complexion if you are Coloured

Light

Medium

Dark

Prominent Hand

Right

Left

Ambidextrous

Face & Body Shape

Face Shape - Which shape below best represents your face shape

Oval

Long

Round

Square

Heart

Body Type - Which body type below best represents your body

Thank you for filling in the the next section of the form.

Here's another testimonial from one of our Donor Angels:

I am good after my donation today and I was so happy that I did this today. I feel so blessed …..thanks so much for the love and support you guys gave me and for the patience you guys had … I would love to do this again.

Thank You!

Thank you so much for filling in the form so far.

Please fill in as many fields as possible...

Physical Characteristics

Describe your personality

Describe how you think others see you

What excites and motivate you in life

What saddens you in life

What is most important to you in life

What character/personality trait do you have that you are most proud of

What personal dreams and goals do you have for yourself

Who do you look up to in life and why

If you had more money than you needed, what would you do with it

If you could spend a day with anyone in the world (living or deceased) who would it be and why

Do you have any hobbies or special interests

Donation Insights

Why have you decided to become an egg donor?

What special message would you like to send the prospective parents

Thank you for filling in the next section of the form.

Here's another testimonial from one of our Donor Angels:

The medical team and assisting personnel were all friendly, direct and helpful. They made everything simple and yet extraordinary. I was taken great care of and am blessed to have had the privilege to assist in building a family.

Awesome!!!

You've Reached the half way point of the form

Please continue to the next section and tell us more about you...

Lifestyle

Describe your general health

Do you smoke cigarettes?

Yes

Do you consume alcohol? How many units per week

How would you describe your diet

Do you exercise? How many times per week

Have you excelled in any sports and/or do you play any competitive sports

Education & Employment

How would you describe your performance at school/marks achieved

What is your highest completed High School Grade

Which were your favourite subjects

Did you achieve any special awards or merits at school or thereafter

Please detail any post school diplomas/degrees/certificates that you achieved

How would you describe your level of intelligence

Are you currently studying or planning to study. Please elaborate

Are you currently employed? Please provide details

Do you have any long-term career/work orientated goals? Please elaborate

What would be your ideal job/way in which to spend your working days, if money was not an issue

Thank you for filling in the the next section of the form.

Here's another testimonial from one of our Donor Angels:

I had a lovely experience as an egg donor. It’s such an honour to be able to help someone build their family. I would gladly do it again.

Well Done!!!

You have earned your Egg Donor Angel wings.

Please tell us more about your family...

Family Heritage & Characteristics

Mother

Race (Mother)

Country of Birth (Mother)

Ethnic Heritage (Mother) E.g. (South African, Zulu, Dutch, Xhosa, Irish etc

Age (Mother)

Eye Colour (Mother)

Hair Colour (Mother)

Height in Meters (Mother)

Father

Race (Father)

Country of Birth (Father)

Ethnic Heritage (Father)

Age (Father)

Eye Colour (Father)

Hair Colour (Father)

Height in Meters (Father)

Siblings

Please include information for ALL full AND half siblings

Sibling 1

Race (Sibling 1)

Country Of Birth (Sibling 1)

Ethnic Heritage (Sibling 1)

Age (Sibling 1)

Eye Colour (Sibling 1)

Hair Colour (Sibling 1)

Height in Meters (Sibling 1)

Sibling 2

Race (Sibling 2)

Country of Birth (Sibling 2)

Ethnic Heritage (Sibling 2)

Age (Sibling 2)

Eye Colour (Sibling 2)

Hair Colour (Sibling 2)

Height in Meters (Sibling 2)

Sibling 3

Race (Sibling 3)

Country of Birth (Sibling 3)

Ethnic Heritage (Sibling 3)

Age (Sibling 3)

Eye Colour (Sibling 3)

Hair Colour (Sibling 3)

Height in Meters (Sibling 3)

Sibling 4

Race (Sibling 4)

Country of Birth (Sibling 4)

Ethnic Heritage (Sibling 4)

Age (Sibling 4)

Eye Colour (Sibling 4)

Hair Colour (Sibling 4)

Height in Meters (Sibling 4)

Sibling 5

Race (Sibling 5)

Country Of Birth (Sibling 5)

Ethnic Heritage (Sibling 5)

Age (Sibling 5)

Eye Colour (Sibling 5)

Hair Colour (Sibling 5)

Height in Meters (Sibling 5)

Sibling 6

Race (Sibling 6)

Country of Birth (Sibling 6)

Ethnic Heritage (Sibling 6)

Age (Sibling 6)

Eye Colour (Sibling 6)

Hair Colour (Sibling 6)

Height in Meters (Sibling 6)

Sibling 7

Race (Sibling 7)

Country of Birth (Sibling 7)

Ethnic Heritage (Sibling 7)

Age (Sibling 7)

Eye Colour (Sibling 7)

Hair Colour (Sibling 7)

Height in Meters (Sibling 7)

Sibling 8

Race (Sibling 8)

Country of Birth (Sibling 8)

Ethnic Heritage (Sibling 8)

Age (Sibling 8)

Eye Colour (Sibling 8)

Hair Colour (Sibling 8)

Height in Meters (Sibling 8)

Maternal Grandmother

Maternal meaning your mother's side of the family

Race (Maternal Grandmother)

Country of Birth (Maternal Grandmother)

Ethnic Heritage (Maternal Grandmother)

Age (Maternal Grandmother)

Eye Colour (Maternal Grandmother)

Hair Colour (Maternal Grandmother)

Height in Meters (Maternal Grandmother)

Maternal Grandfather

Maternal meaning your mother's side of the family

Race (Maternal Grandfather)

Country of Birth (Maternal Grandfather)

Ethnic Heritage (Maternal Grandfather)

Age (Maternal Grandfather)

Eye Colour (Maternal Grandfather)

Hair Colour (Maternal Grandfather)

Height in Meters (Maternal Grandfather)

Paternal Grandmother

Paternal meaning your father’s side of the family

Race (Paternal Grandmother)

Country of Birth (Paternal Grandmother)

Ethnic Heritage (Paternal Grandmother)

Age (Paternal Grandmother)

Eye Colour (Paternal Grandmother)

Hair Colour (Paternal Grandmother)

Height in Meters (Paternal Grandmother)

Paternal Grandfather

Paternal meaning your father’s side of the family

Race (Paternal Grandfather)

Country of Birth (Paternal Grandfather)

Ethnic Heritage (Paternal Grandfather)

Age (Paternal Grandfather)

Eye Colour (Paternal Grandfather)

Hair Colour (Paternal Grandfather)

Height in Meters (Paternal Grandfather)

Thank you for filling in the the next section of the form.

Here's the next testimonial from one of our Donor Angels:

The experience was great and what an honor it is to be able to help someone to build a family. Thank you so much for the opportunity and I hope to hear from you soon.

Brilliantly Done!!!

You have earned your Egg Donor Angel halo.

Please tell us more about your family...

Family Medical Health History

Mother

Health Status (Mother)

If deceased age & cause (Mother)

Father

Health Status (Father)

If deceased age & cause (Father)

Sibling 1

Health Status (Sibling 1)

If deceased age & cause (Sibling 1)

Sibling 2

Health Status (Sibling 2)

If deceased age & cause (Sibling 2)

Sibling 3

Health Status (Sibling 3)

If deceased age & cause (Sibling 3)

Sibling 4

Health Status (Sibling 4)

If deceased age & cause (Sibling 4)

Maternal Grandmother

Maternal meaning your mother's side of the family

Health Status Maternal Grandmother

If deceased age & cause Maternal Grandmother

Maternal Grandfather

Maternal meaning your mother's side of the family

Health Status (Maternal Grandfather)

If deceased age & cause (Maternal Grandfather)

Paternal Grandmother

Paternal meaning your father’s side of the family

Health Status (Paternal Grandmother)

If deceased age & cause (Paternal Grandmother)

Paternal Grandfather

Paternal meaning your father’s side of the family

Health Status (Paternal Grandfather)

If deceased age & cause (Paternal Grandfather)

Thank you for filling in the the next section of the form.

Here's another testimonial from one of our Donor Angels:

Thank you so much for your lovely email; I always feel so much better after hearing from you. Your work and role is so beautiful and I am sure it is quite hard at times, but you do this with such grace, empathy and love.

You are Great!!!

Thank you so much for filling in the form so far. You are one of those rare individuals who cares for others.

Please tell us more about your family...

Genetic Testing

Please indicate "Yes" only if you know you are a carrier of the conditions below, otherwise leave blank.

Tay Sachs Disease

Yes

Sickle Cell Disease

Yes

Thalassemia

Yes

Cystic Fibrosis

Yes

Medical History

* Important: Please note that this section is compulsory and each question must be filled in.

* Please indicate below, whether you or a family member (only biological family) suffer or have suffered from any of the following.

* Please, for the answers:

Y

for Yes

N

for No

U

for Unknown

* If the answer is Yes then please indicate the family member and the outcome.

* If you answered Yes in the cancer field, please indicate the family member and type of cancer.

Acne

ADHD

Alcoholism

Anaemia

Arthritis

Asthma

Allergies

Autoimmune

Blindness

Blood Transfusion

Cancer (type & age of onset)

Cataracts

Cerebral Palsy

Cleft Palate

Deafness

Deformities

Depression/Mental Illness

Diabetes (if insulin dependent at what age)

Disabilities

Downs Syndrome

Dwarfism

Eczema

Emphysema

Endometriosis

Epilepsy

Fertility Issues

Glaucoma

Genetic/Hereditary Diseases

Haemophilia/bleeding disorder

Heart problems

High Blood Pressure

High Cholesterol

HIV/Aids

Kidney Disease

Learning Disability

Leukaemia

Liver Disease

Migraines

Multiple Sclerosis

Muscular Dystrophy

Osteoporosis

Ovarian Cysts

Senility before age 50

Spina Bifida

Substance Abuse

Tuberculosis

Thyroid Disease

Ulcers

Other

Thank you for filling in the the next section of the form.

Here's another testimonial from one of our Donor Angels:

I would still love to be kept on the data base for future donations that might help someone in need. My experience at Cape Fertility was very positive – a friendly and professional place. I felt at ease and comfortable with the whole process. Dr Pottow made the journey easy. I am happy to know that I got a chance to help when I could.

You are an Angel!!!

Well done you have filled in all your personal details. You have achieved your Egg Donor Angel status.

Please fill in this last bit so we may process your application - thank you!

For Office Use Only - Please Complete (answering all questions)

This section is confidential and is never shared with anyone outside of our clinic.

First Name

Surname

Cell phone/ Whatsapp number

Family member/friend cell number and relationship to you

Email address

Full Physical address

ID or Passport Number

Exact Height

Exact Weight

If you do not know your weight and height you must get measured.

Very Important

If married, does your husband approve of you donating your eggs?

Have you ever been diagnosed with infertility in the past or had difficulty conceiving for more than 1 year? If so, please provide details.

Are You HIV Positive or Negative

Positive (have it)

Negative (don't have it)

Do you suffer from type 1 diabetes?

Yes

Do you take any thyroid medication? Please advise name & dosage

If you have recently had a baby, please note that you may only donate after 6 months post the birth. If you are breastfeeding, please finish breastfeeding before you apply to donate

Are you currently on any medication? If so, please detail

Have you ever been under the care of a psychiatrist or psychologist? Please provide details

Are you on any medical for mental illness (eg, anti-depressants?)

Are you a virgin?

Yes

How many sexual partners have you had in the past 5 years

Have you been treated for any Sexually Transmitted Infections (STIs) in the last 5 years? Infections like Chlamydia, Gonorrhoea, HIV, Hepatitis B or C, Syphilis, or any other.

Have you ever injected IV narcotic drugs e.g. Heroin

Yes

Do you use Cannabis and if so when last did you use it?

Are you taking any contraceptive such as pill, injection or IUD (Copper T or Mirena) to prevent pregnancy?

Yes

Have you had any termination of pregnancies before, and if so were there any medical complications?

Do you have regular or irregular menstrual periods? Do you sometimes not have periods for a few months?

Regular

Irregular

Have you been diagnosed with Polysystic Ovary Syndrome before (PCOS), and if so are your periods regular or irregular?

Have you had a tubal sterilisation or had a fallopian tube removed or found to be damaged?

Have you been diagnosed with any other gynaecological conditions? Please explain

Have you ever applied to be a donor with another agency and had your application declined? If yes, state the reason you were declined

Have you donated before? If yes please be aware that we will call you for the following information regarding your previous donation/s: Month & year you donated. The clinic at which you donated. The agency through which you donated. The number of eggs retrieved if you know this detail

Have you read and understood the Egg Donor Information Document provided?

Yes

If you have not yet read the Egg Donor Information Document, please do so by clicking here...

Do you understand and consent to having the fertility specialist check your ovaries with a standard internal vaginal scan? *** Very Important - please note that if your answer in "no" then you will not be eligible for the Donor Program

Yes

No (Please note that if your answer in "no" then you will not be eligible for the Donor Program)

Donors Declaration

Please indicate Yes if you agree with each of the statements below.

I have made myself available as an egg donor with Cape Fertility Egg Donor Program of my own free will

I understand that the recipients have invested time, emotion and finances and I agree to act responsibly in my commitment to donate for them

I confirm that the information provided herein is true, accurate and complete to the best of my knowledge

I confirm that the pictures provided are of me

I understand and agree to attend all scheduled appointments arranged, on time

I agree to take the medication prescribed for me as directed by the clinic

I understand and agree that I have no parental rights over any children resulting from the donation of my eggs

I understand and agree to be available for one full day on the day of my egg retrieval and understand that I may not drive myself home on this day.

Congratulations and thank you for your time and patience in completing your personal Egg Donor Profile. Please now send it back to us and we will acknowledge receipt.
We will revert to you once we have reviewed your profile and advise you that you are on our Database and available for selection.

We look so forward to having you join our egg donor family!

Now all you have to do is Push the Submit button!!

Spread the giving!