Institute for Reproductive Health
It is important for you to understand that receiving egg donor compensation may jeopardize your eligibility for certain government programs, including but not limited to Medicaid, Care Source and Amerigroup insurance for yourself and your family. It is your responsibility to understand your health insurance benefits and how any compensation may affect your eligibility for these programs.
1. Are you eligible to work in the United States?
 
"" 
2. Are you a US citizen or permanent resident?
 
"" 
3. FIRST name
 
250 characters remaining "" 
4. LAST name
 
250 characters remaining "" 
5. Street address? (include apartment if approprate)
 
250 characters remaining "" 
6. City
 
250 characters remaining "" 
7. State
 
"" 
8. Zip Code
 
250 characters remaining "" 
9. Primary Phone Number
 
250 characters remaining "" 
10. Text friendly cell phone number (enter N/A if you don't have a text friendly phone or capability, otherwise enter the actual number)
 
250 characters remaining "" 
11. Date of Birth
 
   
12. In which country were you born?
 
"" 
13. Are you adopted?
 
"" 
14. What race do most people consider you to be?
 
"" 
If multi-racial, please provide your closest description.
15. Height
 
"" 
16. Weight
 
"" 
17. What is your highest level of completed education?
 
"" 
18. Is your work schedule flexible?
 
"" 
Please provide times when you definately are not available.
19. Are you currently enrolled as an egg donor in another program?
 
"" 
20. How many times have you donated your eggs?
 
"" 
21. Do you have both ovaries?
 
"" 
22. Are your currently breastfeeding?
 
"" 
23. Have you ever been told you were infertile?
 
"" 
If yes, when and why?
24. Have you ever been refused or denied as a blood donor?
 
"" 
If yes, why?
25. Have you ever used recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)?
 
"" 
If yes, which one(s) and when did you last use them?
26. How may brothers, sisters & parents in your family have a history of alcohol or drug abuse?
 
"" 
27. Have you had ear and/or body piercings or tattooing on your body?
 
"" 
If yes, please provide details.
28. Do you drink alcoholic beverages?
 
"" 
29. How many drinks do you usually consume in a week?
 
"" 
30. How many cigarettes do you smoke per day?
 
"" 
31. Why do you want to become a donor?
 
250 characters remaining "" 
32. I understand that receiving egg donor compensation may jeopardize my eligibility for certain government programs, including but not limited to Medicaid, Care Source and Amerigroup insurance for myself and my family. I further understand that it is my responsibility to understand my health insurance benefits and how any compensation may affect my eligibility for these programs.
 
"" 
33. Do you have Medicaid, CareSource or Amerigroup medical insurance?
 
"" 
34. What is your email address for communication with you regarding your pre-screen application?
   
34. Please verify your email address
   
35. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
36. Verify your password