Thank you for your interest in becoming an egg donor at Atlanta Center for Reproductive Medicine.

An egg donor is a woman between the ages of 21 and 29. She can be single or married and may already have children of her own.

In an anonymous egg donor cycle, all identifying information about you is kept confidential from your recipient. You will not be given any information about the recipient or the eggs that you have donated or the outcome of your cycle.

We are excited about your interest in donating eggs to infertile couples who desperately need them! Know that these couples will be forever grateful to you for this gift! It is only by gifts such as yours that many couples can achieve their dream of having children, and we are sincerely appreciative.

Please fill out our questionnaire and we will contact you once it is completed.
1. What is your FIRST name?
 
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2. Date of Birth (only your calculated age is shared with Recipients)
 
   
3. What is your height?
 
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4. What is your weight?
 
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5. What race would you most likely be affiliated?
 
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If Multi-race or Other, please provide your closest description
6. What is your highest level of completed education?
 
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Please list the degree you are pursuing
7. Are you a US citizen or permanent resident?
 
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8. Are you eligible to work in the United States?
 
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9. Is your work schedule flexible?
 
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10. Are you adopted?
 
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11. Do you have both ovaries?
 
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12. What kind of contraception do you use?
 









If "Other", please explain.
13. How many cigarettes do you smoke per day?
 
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14. When is the last time you had marijuana?
 
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15. When is the last time you have used recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)?
 
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16. In the past 12 months, have you been exposed to known or suspected HIV, hepatitis B, and/or hepatitis C infected blood through contact with an open wound, non-intact skin, or mucous membrane?
 
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17. In the past 12 months, have you been in juvenile detention, lock up, jail or prison for more than 72 consecutive hours?
 
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18. In the past 12 months, have you had tattooing, ear piercing or body piercing in which sterile procedures were not used?
 
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19. In the past 12 months, have you been treated for or had Syphilis, Chlamydia or Gonorrhea?
 
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20. Have you spent 5 or more years cumulative in Europe since 1980?
 
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21. By selecting "Agree", you are stating that you understand the the results of this pre-screen will be sent to you from no-reply@donorapplication.com. I understand this email must be accepted by my spam filters.
 
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22. By selecting "Agree", you are stating that you have answered all questions to the best of your ability, without purposeful omission or deception. You understand that egg donation is considered "tissue donation" according to the FDA.
 
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23. By selecting "Agree", you are stating that you understand the importance of remaining anonymous to the recipient. We will make all reasonable efforts to protect your identity.
 
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24. How did you hear about us? (PLEASE SELECT ALL THE WAYS YOU HAVE HEARD ABOUT US)
 















If Other, Please Explain
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.
   

Please add no-reply@donorapplication.com to your email contact list to prevent our response from being flagged as spam.