Sperm Donor Application

SPERM DONOR APPLICATION

YOUR NAME(Required)

First Middle Last

PREFERRED NAME / NICKNAME

EMAIL ADDRESS(Required)

PHONE NUMBER(Required)

ADDRESS(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

U.S. CITIZENSHIP STATUS(Required)

DATE OF BIRTH(Required)

More About You

MATERNAL ANCESTRY LINE(Required)

Nationality/Heritage

PATERNAL ANCESTRY LINE(Required)

Nationality/Heritage

WHAT IS YOUR ETHNICITY?(Required)

WHAT IS YOUR RELIGIOUS AFFILIATION, IF ANY?(Required)

WHERE WERE YOU BORN AND RAISED?(Required)

HEIGHT(Required)

CURRENT WEIGHT(Required)

SKIN TYPE(Required)

EYE COLOR(Required)

HAIR COLOR(Required)

HAVE YOU EVER DONATED SPERM BEFORE? IF SO, HOW MANY TIMES AND WHAT CLINIC(S)?(Required)

ARE YOU CURRENTLY ENROLLED AS A SPERM DONOR IN ANOTHER PROGRAM? IF SO, PLEASE LIST THE PROGRAM(Required)

HAVE YOU EVER APPLIED OR BEEN SCREENED TO BE AN SPERM DONOR BEFORE?(Required)

Yes

IF YES TO THE ABOVE QUESTION, LIST NAME(S) OF THE DONOR PROGRAMS(Required)

HAVE YOU EVER BEEN CONVICTED OF A CRIME? IF SO, PLEASE LIST WHEN AND THE NATURE OF THE CRIME(Required)

HIGHEST LEVEL OF EDUCATION COMPLETED(Required)

ACT OR SAT SCORE (OR THE EQUIVALENT IN YOUR COUNTRY)(Required)

IF YOU ARE CURRENTLY ENROLLED IN COLLEGE, WHICH UNIVERSITY ARE YOU ATTENDING?(Required)

WHAT IS YOUR MAJOR?(Required)

DEFREES EARNED (IF ALREADY GRADUATED BEFORE)(Required)

OTHER ACHIEVEMENTS OR HONORS(Required)

Medical / Health History

DO YOU OR HAVE YOU SUFFERED FROM ANY SERIOUS ILLNESSES, DISABILITIES, OR HEALTH CHALLENGES? IF SO, PLEASE EXPLAIN(Required)

DOES ANYONE IN YOUR FAMILY SUFFER FROM ANY SERIOUS ILLNESS? IF SO, PLEASE EXPLAIN(Required)

DOES YOUR FAMILY HAVE ANY HISTORY OF MENTAL ILLNESS? IF SO, PLEASE EXPLAIN(Required)

HAVE YOU BEEN DIAGNOSED WITH DEPRESSION, ADD, ADHD, BIPOLAR DISORDER, OR ANY OTHER MENTAL ILLNESS? IF SO, PLEASE EXPLAIN(Required)

IS THERE ANY HISTORY OF CANCER IN YOUR FAMILY? IF SO, PLEASE EXPLAIN(Required)

HOW OFTEN DO YOU SMOKE CIGARETTES OR VAPE?(Required)

HOW MANY ALCOHOLIC DRINKS DO YOU CONSUME ON A WEEKLY BASIS?(Required)

DO YOU USE DRUGS CURRENTLY? (MARIJUANA INCLUDED)(Required)

HOW OFTEN DO YOU USE MARIJUANA?(Required)

HAVE YOU EVER SUFFERED OR CURRENTLY SUFFER FROM ALCOHOLISM?(Required)

Yes

HAVE YOU EVER SUFFERED OR CURRENTLY SUFFER FROM DRUG ADDICTION?(Required)

Yes

ARE YOU TAKING ANY MEDICATIONS? IF SO, PLEASE LIST THEM(Required)

HAVE YOU EVER USED MEDICATIONS SUCH AS ANTIANXIETY/ANTIDEPRESSANTS TO TREAT AN EMOTIONAL OR PSYCHOLOGICAL PROBLEM? IF SO, PLEASE EXPLAIN WHY AND THE DATE LAST TAKEN(Required)

HAVE YOU EVER USED TESTOSTERONE REPLACEMENT THERAPY OR ANABOLIC STEROIDS? IF YES, EXPLAIN(Required)

HAVE YOU HAD ANY TATTOOS OR PIERCINGS IN THE LAST 12 MONTHS? IF YES, EXPLAIN(Required)

HAVE YOU HAD ANY SURGERIES? IF SO, PLEASE EXPLAIN(Required)

HAVE YOU HAD ANY HOSPITILIZATIONS (OTHER THAN THE SURGERIES LISTED ABOVE)?(Required)

WHAT BLOOD TYPE ARE YOU?(Required)

Sex / Reproductive Health History

IN THE PAST 12 MONTHS, HAVE YOU BEEN SEXUALLY ACTIVE WITH A PERSON KNOWN OR SUSPECTED TO HAVE HIV?(Required)

Yes

HAVE YOU EVER TESTED POSITIVE FOR HIV OR HTLV? IF YES, PLEASE EXPLAIN(Required)

Yes

IN THE PAST 12 MONTHS, HAVE YOU LIVED WITH ANOTHER PERSON WHO HAS HEPATITIS-B OR HEPATITIS-C INFECTION?(Required)

Yes

IN THE PAST 12 MONTHS, HAVE YOU TESTED POSITIVE OR BEEN TREATED FOR AN STD SUCH AS ONORRHEA, CHLAMYDIA OR SYPHILIS?(Required)

Yes

HAVE YOU BEEN DIAGNOSED WITH GENITAL HERPES OR HPV?(Required)

Yes

HOW MANY SEXUAL PARTNERS HAVE YOU HAD IN THE PAST 6 MONTHS?(Required)

AFTER YOUR INITIAL SPERM DEPOSIT AT THE CLINIC, YOU WILL NEED TO BE RETESTED ON AN STD PANEL 3-6 MONTHS LATER DUE TO FDA REGULATIONS, ARE YOU WILLING TO GO BACK INTO A LOCAL LAB FOR A QUICK BLOOD DRAW 3-6 MONTHS AFTER DONATION?(Required)

Yes!

ARE YOU RELIABLE AND COMMITTED TO THE SPERM DONATION PROCESS, AND ABLE TO MAKE APPOINTMENTS?(Required)

Yes!

DID YOU READ THE FAQ SECTION TO KNOW WHAT SPERM DONATION ENTAILS?(Required)

Yes!

THIS PART OF THE APPLICATION IS FOR INTENDED PARENTS TO GET TO KNOW YOU BETTER. BE DETAILED.

WHY DO YOU WANT TO BECOME AN SPERM DONOR?(Required)

ANYTHING SPECIAL YOU WOULD LIKE TO TELL US ABOUT YOU?(Required)

HOW WOULD OTHER PEOPLE DESCRIBE YOU?(Required)

DESCRIBE YOURSELF TO US(Required)

WHAT ARE YOUR SPECIAL TALENTS?(Required)

WHAT WOULD YOU CONSIDER TO BE YOUR GREATEST STRENGTHS?(Required)

WHAT IS AN ACCOMPLISHMENT THAT YOU ARE MOST PROUD OF?(Required)

WHO ARE THE MOST IMPORTANT PEOPLE IN YOUR LIFE?(Required)

WHO ARE YOU CLOSEST TO IN YOUR FAMILY AND WHY?(Required)

WHAT IS YOUR FAVORITE FOOD TO EAT?(Required)

WHAT IS A BOOK YOU LOVE TO READ?(Required)

BOOK(S) THAT YOU ARE CURRENTLY READING(Required)

PLACES YOU WOULD LOVE TO TRAVEL(Required)

ACTIVITIES OR HOBBIES THAT YOU ENJOY(Required)

WHAT IS ONE CHANGE YOU WISH TO SEE IN THE WORLD?(Required)

WHAT ARE YOUR FAVORITE WORDS TO LIVE BY?(Required)

DO YOU CURRENTLY WORK? IF SO, WHAT DO YOU DO?(Required)

WHAT WAS THE MOMENT THAT MADE YOU CHOOSE YOUR FIELD OF STUDY OR CAREER?(Required)

WHERE DO YOU SEE YOURSELF IN 10 YEARS?(Required)

HOW DID YOU GET TO WHERE YOU ARE IN LIFE?(Required)

IF YOU COULD TELL THE INTENDED PARENTS WHO ARE CONSIDERING YOU ONE THING, WHAT WOULD IT BE?(Required)

DO YOU WANT TO MEET YOUR INTENDED PARENTS SOMEDAY OR A CHILD IF IT RESULTS FROM YOUR DONATION?(Required)

HOW DID YOU HEAR ABOUT LUXE IVF?(Required)

HOW DO YOU WANT US TO REACH YOU?(Required)

WILL YOU PROVIDE YOUR INSTAGRAM/FACEBOOK USERNAME? IF SO, PLEASE LIST(Required)

PHOTO UPLOAD(Required)

Please upload a photo of yourself.

Max. file size: 512 MB.

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