Confidentiality Agreement

If you are human, leave this field blank.

First Name: *

Last Name: *

Gender:

Female

Male

Age:

Marital Status:

Partner's First Name (if applicable):

Partner's Last Name (if applicable):

Gender:

Male

Female

Language:

State: *

Country: *

How would you like to be contacted?

Contact Preference:

Phone Number: *

May we leave a voice mail to this phone number?: *

Yes

Email Address: *

Mailing Address:

Service

Are you searching for an Egg Donor? *

Yes

Are you searching for a Surrogate? *

Yes

When will you be ready to start?:

When is the best time to contact you?:

Which clinic are you working with?: *

How did you locate our website?:

Criteria you are looking for in an Egg Donor:

Criteria you are looking for in a Surrogate:

Questions / Comments:

Signatures

By entering your name below, you acknowledge that you are signing this document electronically and agree that your digital signature will be binding. Your digital signature on this document represents that you agree to the terms of this Website Confidentiality Agreement.

Digital Signature: *

Date: *

Except for Client’s family members, Client agrees not to disclose to any third party, or use in any manner, information furnished by Las Vegas Egg Donation, including but not limited to, terms of engagement, costs, fees, processes, time frames, sources, names of other parties, data from any portion of Las Vegas Egg Donation's list of donors or interviews of persons anticipated or employed to meet Client’s needs. Client will not disclose the confidential information to any person or party without the specific written authorization of Las Vegas Egg Donation.

I confirm: *

I agree

For access to our Egg Donor Database, or for any information requests, please fill out and submit the application and confidentiality agreement below.

How would you like to be contacted?

Service

Signatures