Sharing the Gift of Life is Truly a Wonderful Blessing and We Can’t Wait to Begin Your Journey Together.
First Name
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Last Name
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Date of Birth
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Phone
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Email
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How Would You Like to be Contacted?
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Text
Phone
Email
Please Give Us the First and Las Name of the Person Who Referred You to Us
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Height (Feet and Inches)
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Weight (Pounds)
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What is Your Primary Race/Ethnic Origin?
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What is Your Highest Level of Education:
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No Diploma/GED
High School Diploma
GED
Job Training
Some College
Associates Degree
Bachelors Degree
Masters Degree
Doctorate Degree
What is Your Current Relationship Status?
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Single
Married
Committed Relationship
Legally Separated
Divorced
Widowed
Citizenship Status
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US Citizenship
US Permanent Resident
Non-US Citizenship
Please Tell Us the Name of the Country of Your Citizenship
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Please Select the Most Accurate Response to Your Experience in Donating Eggs.
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Never Applied Before
Applied and Was Previously Denied
Previously Accepted but Never Donated
Donated Once
Donated Twice
Donated 3 Times
Donated 4 Times
Donated 5 Times
Donated More Than 5 Times
Have You Completed Egg Donation Cycles That Have Resulted in Pregnancy?
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Yes
No
I Don't Know
Is There Anything in Your History, the History of Someone You Have Been Intimate with, or Someone Whom You Live, Related To: (Please hold down "command" or "control" key to select more than one answer)
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PLEASE CHECK ALL THAT APPLY
Blood Diseases or Disorders
Smallpox or Recent Vaccines
Infections, Including HIV
Sepsis, Dementia, Creutzfeldt-Jakob Disease, or Any Severe Illness
Hepatitis A, B, or C
Skin Disorders, Rashes, Including Jaundice
West Nile Virus, HTLV, T-Cell or Enlarged Liver
Any Neurological Condition
Having Received External "Human or Non-Human Transplant Treatments"
I Don't Know
None of the Above
Is There Anything in Your History or the History of Someone With Whom You Have Been Intimate, Who Has Ever: (Please hold down "command" or "control" key to select more than one answer)
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PLEASE CHECK ALL THAT APPLY
Self - Been to Africa
Self - Been to Europe More Than 3 Months
Self - Been to Europe Between 1980-1996
Self - Sexually Transmitted Disease
Self - Drug Abuse or Injected Drugs
Self - Jail/Prison More Than 3 Days
Intimate Partner - Been to Africa
Intimate Partner- Been to Europe More Than 3 Months
Intimate Partner - Been to Europe Between 1980-1996
Intimate Partner - Sexually Transmitted Disease
Intimate Partner - Drug Abuse or Injected Drugs
Intimate Partner - Jail/Prison More Than 3 Days
I Don't Know
None of the Above
Which of the Following Have You Had? (Please hold down "command" or "control" key to select more than one answer)?
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PLEASE CHECK ALL THAT APPLY
Unexplained Weight Loss
Unexplained Night Sweats
Swollen Lymph Nodes Longer Than a Month
Scabs That Wouldn't Heal in 3 Weeks
White Spots in Mouth
Unexplained Temperature > 100.5 degrees Fahrenheit (38.6 Celsius) Longer Than 10 Days
Unexplained Cough or Shortness of Breath
Unexplained Persistent Diarrhea
Unexplained Weakness in Lower Extremities
I Don't Know
None of the Above
Please Select the Best Answer Related to Your Smoking Habits (Including Any Form of Nicotine Products, Such as E-cigarettes, Vaping, Hookah, Etc.)
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Over 10 Cigarettes/E-cigarettes Per Week
4-10 Cigarettes/E-cigarettes Per Week
1-3 Cigarettes/E-cigarettes Per Week
Quit, 0-6 Months Ago
Quit, 7-12 Months Ago
Quit, Over a Year Ago
Never
If You Smoke, Are You Willing to Quit?
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Yes
No
I Don't Know
When is the Last Time You Have Used Recreational Drugs, Such as: Cocaine, Barbituates, Narcotics, Opiates, Amphetmines, Hallucinogens, Tranquilizers (Non-Medical), PCP, Inhalants, Steriods (Non-Medical), Ecstacy, or Other Recreational Drugs for NON-MEDICAL purposes?
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Never
0-6 Months Ago
7-12 Months Ago
Over 1 Year Ago
1-5 Years Ago
Over 5 Years Ago
Please Provide the Name of the Drug(s) Used.
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Have You Had a Tattoo Placed in the Last 6 Months?
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Yes
No
Date Tattoo Was Placed
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What is the Most Number of Consecutive Days That You Have Been Incarcerated?
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30+ Days
11-30 Days
6-10 Days
3-5 Days
2 Days
1 Day
Never
Please explain
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Are You Currently Breastfeeding?
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No
Yes, Will Quit in 3 Months
Yes, Will Quit in 6 Months
Yes, Will Quit in 7-12 Months
Yes, Will Quit After 1 Year
Have you had a Depo Provera Shot Within the Past Year?
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No
Yes, 10-12 Months Ago
Yes, 7-9 Months Ago
Yes, 4-6 Months Ago
Yes, 0-3 Months
Date of Depo Provera Injection
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Do You Have Both Ovaries?
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No
Yes
If No, Please Explain.
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Have You Tested Positive for Chlamydia or Gonorrhea Within the Last Year?
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No
Yes, 0-3 months ago
Yes, 4-6 Months Ago
Yes, 7-9 Months Ago
Yes, 10-12 Months Ago
Date of Positive Test Results
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Have You Ever Had Any of the Following? (Please hold down "command" or "control" key to select more than one answer)
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PLEASE CHECK ALL THAT APPLY
HIV (AIDS)
NSU (Non-Specific Urethritis)
Syphilis
Gonorrhea
Chlamydia
Trichomonas
Venereal Warts
Herpes, Genital
Viral Hepatitis B or C
Genital Sores
Other Sexually Transmitted Diseases
No
Please Provide the Date of the Last Time and Indicate How Many Times Altogether
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Have You Been Seen a Psychiatrist, Psychologist, Social Worker, Counselor or Any Other Mental Health Professional for Any Reason?
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No
Yes, Over 2 Years Ago
Yes, 1-2 Years Ago
Yes, 7-12 Months Ago
Yes, Within the Last 6 Months
Yes, Currently Getting Support
If Yes, For How Long Altogether and For What Reason(s)?
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Have You Ever Used Medications, Such as Anti-Anxiety or Anti-Depressants, to Treat an Emotional or Psychological Problem?
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Yes, Currently Being Used
Yes, Used Within the Last 6 Months
Yes, 7-12 Months Ago
Yes, 1-2 Years Ago
Yes, Over 2 Years Ago
No
If Yes, Please List the Medication, the Reason Why and the Last Date Used
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Are You Adopted?
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No
Yes
If you are human, leave this field blank.