XYTEX PHOTOMATCHING FORM
Please fill out the following information. Please print.
NAME:________________________________ PHONE:_______________________________
ADDRESS:___________________________________________________________________
E-MAIL ADDRESS:____________________________________________________________
Thank you for your interest in Xytex's PhotoMatching Service. The following information, along with photos will help us provide you with 2-4 donors who meet most of your criteria. Xytex Corporation cannot make your donor decision for you. This photomatching service is to make suggestions based on photos and information that you have provided Xytex.
Blood type is medically important only to recipients who are Rh negative. Any questions about donor blood type selection should be discussed with your physician.
The following information will help Xytex determine sample availability:
Physician/Clinic Name:____________________________ Phone:_______________________
Physician Address:____________________________________________________________
Type of units required? Washed____Unwashed____(Washed for IUI, Unwashed for ICI or IVF)
Please enclose your $200.00** payment in U.S. funds with this form.
Select One:Visa______MasterCard______Discover______American Express_________
Credit Card Number:___________________________________________________________
Expiration Date:_______________________________________________________________
Name on Card________________________________________________________________
Security code on Card__________________________________________________________
Billing address associated with Card________________________________________________
Certified Check/Money Order Number:_____________________________________________
**This $200.00 payment is for our PhotoMatching service and includes an adult photo of the selected donor (if available) and an enhanced profile.
Send this form, photos and payment to:
Xytex Corporation
Attn: Mary Hartley
1776 Peachtree Street, NE
Suite 175
Atlanta, GA 30309
Atlanta E-mail address: mhartley@xytex.com
Please complete the following information on the individual to whom we are matching donors (in other words, whomever the donor should resemble); also rate the importance of that particular trait (1=very important, 5=least important.
Ethnic Group:_____________________________________________________Rating:________
Eye Color:________________________________________________________Rating:________
Hair Color/Texture:_______________________________________________Rating:________
Height/Weight:____________________________________________________Rating:________
Body Build (small, medium, large, very large):________________________Rating:________
Skin Tone:________________________________________________________Rating:________
Blood Type:___________________________________________________________Rating:________
Occupation:___________________________________________________________Rating:________
Additional Info/Special Skills:_______________________________________Rating:________
_____________________________________________________________
Recipient's (your) Information
Race/Ethnic Group:____________________________________________________Rating:________
Eye Color:____________________________________________________________Rating:________
Hair Color/Texture:___________________________________________________Rating:________
Height/Weight:________________________________________________________Rating:________
Body Build (small, medium, large, very large):________________________Rating:________
Skin Tone:____________________________________________________________Rating:________
Blood Type:___________________________________________________________Rating:________
Please include any other information that you would like Xytex to consider in the selection process.
Thank you again for your assistance. Xytex will return your photos along with a letter and a list of proposed donors as soon as possible. (Please allow 10-14 days.)
