UNC Fertility
1. FIRST name
 
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2. LAST name
 
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3. Street address? (include apartment if approprate)
 
---> Street Address Apartment City State Zip
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4. Based on the following address: (7920 ACC Blvd, Suite 300, Raleigh, NC 27617) ... how much time will it take to get to this location? (typical treatment cycle is 11 visits)
 
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5. What is the primary phone number (include area code) to use for contact and leaving messages?
 
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6. Please select the most accurate response to the decision tree related to your eligibility to work in the USA, your residency, and your citizenship.
 
7. What is your highest level of completed education?
 
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8. Closest description of your race. Note: Combinations of multi-racial descriptions are only in 1 menu. For example, "Black and Latin/Hispanic" is not listed in "Latin/Hispanic and Black" since they are the same.
 
If any racial descriptions include "Other", please explain.
9. What is your date of birth?
 
   
10. Height
 
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11. Weight
 
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12. Please answer the following decision tree related to smoking habits (including any form of nicotine products, including e-cigarettes).
 
13. Please select the most appropriate answers for tattoos, acupuncture and body piercings.
 
Piercing How Many? Most Recent? Sterile Needles? Most Recent Performed by?
--->:        
Please provide locations of tattoos and piercings.
14. What is your email address for selection notification?
 
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15. Our organization uses a secure server for some email communication with you. The server is www.donorapplication.com. Email will come to you from no-reply@donorapplication.com. The domain of donorapplication.com needs to be acceptable to your spam filters to ensure email communication. (Google: "how to add an email address to safe list in (Outlook, Google, Yahoo, etc.)"
 
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16. How did you hear about our program?
 
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17. What is your email address for communication with you regarding your pre-screen application?
   
17. Please verify your email address
   
18. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
19. Verify your password