Vitalab Egg Donation Agency
 

1. Your First Name
 
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2. Your Surname
 
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3. Your Date of Birth
 
   
4. A Valid Email Address
 
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5. Your Contact Number
 
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6. Where Do You Live (Province)
 
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Other
7. Your Race Group
 
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Please provide "Other" race group.
8. Even though you will be measured for weight in our office, please provide us your weight.
 
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9. Even though you will be measured for height in our office, please provide us your height.
 
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10. What is your highest level of education?
 
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11. How many times have you applied to be an egg donor?
 
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12. How many times have you donated your eggs?
 
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13. Will you be available to donate your eggs in the next 4 to 6 months?
 
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14. Do you smoke?
 
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15. How many cigarettes (or any nicotine product) do you smoke per day?
 
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16. Are you currently taking any medications prescribed or over the counter?
 
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Which medications?
17. Even though you will be tested for Drug use in our offices, have you partaken in the use of any of the below listed Drugs within the last 3 months?
 





18. Are you currently taking any diet pills or herbal medications?
 
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Please list.
19. What kind of birth control method are you currently using?
 








20. Are your menstrual periods regular (27 - 29 days) when not on birth control pills?
 
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21. Have you been diagnosed for any of the following within the last year?
 




22. Are you adopted?
 
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23. How did you FIRST learn about the opportunity to donate your eggs at VEDA?
 
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24. The information that I have provided is correct. I agree to participate in the VEDA Anonymous Confidential Egg Donation Program. I will make myself available to attend all scheduled appointments at the clinic during working days and hours.
 
Please enter your initials here:
25. What is your email address for communication with you regarding your pre-screen application?
   
26. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
27. Verify your password.